abstract book

EMERGENCY
UROGENITAL RADIOLOGY
Ljubljana, Slovenia, September 8-11, 2005
Edited by:
Darja Babnik Peskar
Published by:
Designed by: A.Wabra

CIP - Katalozni zapis o publikaciji
Narodna in univerzitetna knjiznica, Ljubljana
616.6:618(063)(082)
616.6-073(063)(082)
EUROPEAN Symposium on Urogenital Radiology (12 ; 2005 ; Ljubljana)
Emergency urogenital radiology / 12th European Symposium on
Urogenital Radiology - ESUR 05, Ljubljana, Slovenia, September
8-11, 2005 ; edited by Darja Babnik Peskar. - Ljubljana: Slovenian
Association of Radiology: Slovenian Association of Urologists ;
Wien: European Society of Urogenital Radiology, 2005
ISBN 961-90412-3-2 (Slovenian Association of Radiology)
1. Gl. stv. nasl. 2. Babnik Peskar, Darja
221056512
This Syllabus has been kindly sponsored by
GUERBET
© all rights reserved by the
EUROPEAN SOCIETY OF UROGENITAL RADIOLOGY
2

Contents
Acknowledgements 4
ESUR 2005 Organisation 5
ESUR 2005 Faculty 6
Accreditation 7
General information 8
Map of Ljubljana 10
Map of the conference area 11
Programme overview 13
Social programme and guided tours 14
Programme 15
Thursday, 8.9.2005 15
Friday, 9.9.2005 17
Saturday, 10.9.2005 20
Sunday, 11.9.2005 22
POSTER SESSION 23
COURSE LECTURES 26
Urogenital trauma: the traumatologist’s perspective; Matej Cimerman, Matej Jezernik 26
Genitourinary trauma: the urologist's perspective; Miro Mihelic 28
Upper urinary tract trauma; Anders Magnusson 34
Trauma to the urethra and scrotum; Stanford M. Goldman 36
Ureteral and bladder injuries; Carl M. Sandler 38
Urinary obstruction: the urologist's perspective. Imaging and intervention of obstruction; Andrej Kmetec 41
Imaging of stones: plain film, IVU, and ultrasound; Gertraud Heinz-Peer 44
Urinary obstruction: MRU and CTU; Joern Kemper, Claus Nolte-Ernsting 46
Urinary obstruction: radiation and economic aspects; Fulvio Stacul 47
Investigation of microscopic hematuria: the nephrologist’s perspective; Jürgen Floege 48
Urinary bleeding: imaging for suspected benign and malignant diseases; Elaine M. Caoili, Richard H. Cohan 49
Imaging the patient with hemospermia; Parvati Ramchandani 52
Arterial embolization in emergency uroradiology; Tarek A. El-Diasty 55
Urogenital emergencies in the female patient: the obstetrician’s perspective; Tanja Premru-Srsen 56
Urogenital emergencies in the female patient: a gynaecologic aspect; Adolf Lukanovic 58
Preoperative assessment of benign diseases of the female pelvis: endometriosis; Karen Kinkel 62
Preoperative assessment of benign diseases of the female pelvis: adnexal diseases; Izumi Imaoka 64
Clinical aspects of urinary tract infections; Andrej Bren 66
Diagnostic imaging of pyogenic infections in the urinary tract; Takehiko Gokan 67
Tuberculosis and uncommon infections of the urogenital tract; Tarek A. El-Diasty 69
Clinical evaluation of acute renal failure; Rafael Ponikvar 71
Emergencies in kidney transplantation: clinical evaluation and the nephrologist’s perspective; Marko Malovrh 73
Acute renal failure: imaging evaluation of native kidneys; O Hélénon, JM Correas 75
The transplanted kidney: renal emergencies; Jarl Å. Jakobsen 78
The transplanted kidney: extrarenal emergencies; Nicolas Grenier 80
WORKSHOPS 83
RF ablation of renal tumors; Peter L. Choyke 83
Diagnosis of prostate carcinoma: (is there a) role for the radiologist (?); R.H. Oyen 85
Assessment of local extension of prostate cancer by TRUS and TRUS-guided biopsy; François Cornud 87
What to do with a suspicious adnexal mass at US?; Kaori Togashi 89
Imaging of endometrial cancer: The Yorkshire Cancer Network guidelines; S.E.Swift, M.J.W. and J.A. Spencer 91
Pediatric urologic emergencies: imaging in acute urogenital trauma, testicular and ovarian torsion; R. Michael 94
Imaging in acute pediatric urinary tract infections; prof. Kassa Darge 96
Malignant adrenal masses; Gabriel P. Krestin 96
TECHNICAL PROTOCOLS FOR MALE AND FEMALE MRI OF THE PELVIS 99
Magnetic resonance examinations of the male pelvis; Ullrich G. Mueller-Lisse 99
Technical protocols for female MRI of the pelvis; Karen Kinkel 102
CONTRAST MEDIA GUIDELINES 104
Effects of iodinated contrast media on blood and endothelium; P. Aspelin, F. Stacul, A.J. van der Molen,
T. Almén, M.F. Bellini, J.Å. Jakobsen, R. Oyen, J.A.W. Webb, H.S. Thomsen, S.K. Morcos 104
Use of contrast in the emergency department; James H. Ellis 112
ESUR guidelines on contrast medium induced nephropathy; Henrik S. Thomsen 116
ABSTRACTS 121
MEMBERS’ SESSION 121
SCIENTIFIC SESSION 126
POSTER SESSION 137
3

Acknowledgements
ESUR 2005 GRATEFULLY ACKNOWLEDGES
THE SUPPORT OF THE FOLLOWING SPONSORS:
Honorary Sponsors
Minister of Health Slovenia
Mayor of the City of Ljubljana
Main sponsors
Sponsors
4

ESUR 2005 Organisation
ESUR Board
ESUR 2005 Honorary Committee
Lorenzo Derchi President Minister of Health Slovenia
Sameh K. Morcos President-Elect
Mayor of the City of Ljubljana
Gertraud Heinz-Peer Secretary/Treasurer
Jelle O. Barentsz Past-President
Anders Magnusson Member-at-Large
ESUR 2005
Programme Committee
ESUR 2005
Local Committee
Darja Babnik Peskar (SI) Darja Babnik Peskar (SI)
Jelle O. Barentsz (NL) Vladimir Jevtic (SI)
Boris Brkljacic (HR) Ciril Oblak (SI)
Richard Cohan (USA) Eveline Smrtnik (SI)
Nigel Cowan (UK) Bojan Trsinar (SI)
Lorenzo Derchi (I) Nado Vodopija (SI)
Tarek El-Diasty (EG) Ziva Zupancic (SI)
Roberto G. Figueiras
(E)
Nicolas Grenier
(F)
Gertraud Heinz-Peer
(A)
Karen Kinkel
(CH)
Anders Magnusson
(S)
ESUR 2005
Organizing Secretariat
ALPE ADRIA TURIZEM
Smartinska 152 G, 1000 Ljubljana,
Slovenia
Tel.: +386 1 523 33 57
Fax: +386 1 523 33 58
e-mail: dusan@aaturizem.com
ESUR 2005
Scientific Secretariat
Darja Babnik Peskar,
KIR KC Ljubljana, Zaloska 7,
1000 Ljubljana, Slovenia
Tel.: +386 1 522 35 12
Fax: +386 1 522 24 97
e-mail: darja.babnik@kclj.si
5

ESUR 2005 Faculty
P. Aspellin (S) M. Glusic (SI) R. Ponikvar (SI)
D. Babnik Peskar (SI) T. Gokan (J) R. Pozzi-Mucelli (I)
C. Balleyguier (F) S. Goldman (USA) T. Premru-Srsen (SI)
J. Barentsz (NL) N. Grenier (F) M. Prokop (NL)
P. Bosnjakovic (SCG) S. Hanna (EG) S. Rainer (SI)
M. F.Bellin (F) O. Helenon (F) P. Ramchandani (USA)
A. Bergman (S) M. Hellstrom (S) I. Requejo Isidro (E)
R. Berkenblit (USA) Jo Mc Hugo (UK) M. Riccabona (A)
J. G. Blickman (NL) G. Heinz-Peer (A) C. Roy (F)
A. Bren (SI) J. Hubert (F) C. Sandler (USA)
B. Brkljacic (HR) I. Imaoka (J) G. Serafini (I)
M. Budau (RO) J. A. Jakobsen (N) E. Smrtnik (SI)
V. M. Builov (RUS) V. Jevtic (SI) J. Spencer (UK)
E. Caoili (USA) R. Katz (IL) F. Stacul (I)
P. Choyke (USA) J. Kemper (D) R. Stern Padovan (HR)
M. Cimerman (SI) K. Kinkel (CH) K. Sugimura (J)
R. Cohan (USA) A. Kmetec (SI) H. S. Thomsen (DK)
M. Collins (UK) G. Krestin (NL) B. Trsinar (SI)
F. Cornud (F) S. Kupesic (HR) K. Togashi (J)
M. Cova (I) A. Lukanovic (SI) A. Vargha (HU)
N. Cowan (UK) A. Magnusson (S) D. Vidmar (SI)
T. M. Cunha (P) A. Maubon (F) N. Vodopija (SI)
I. Cvitkovic Kuzmic (HR) M. Malovrh (SI) Z. Zupancic (SI)
F. Danza (I) M. Marotti (HR) N. J. Wasserman (USA)
K. Darge (D) M. Mihelic (SI) J. A. W. Webb (UK)
S. Dorf (DK) S. K. Morcos (UK)
T. A. El Diasty (EG) S. Moussa (UK)
L. Derchi (I) U. Muller-Lisse (D)
J. Ellis (USA) U. G. Muller-Lisse (D)
R. G. Figueiras (E) Y. Narumi (J)
J. Floege (DK) C. Oblak (SI)
F. Frauscher (A) R. Oyen (B)
G. Gayer (IL) P. Pavlica (I)
6

Accreditation
The 12th European Symposium on Urogenital Radiology is accredited by the European Accreditation Council
for Continuing medical Education (EACCME) to provide the following CME activity for medical specialists. The
EACCME is an institution of the European Union of Medical Specialists (UEMS). www.uems.be.
The 12th European Symposium on Urogenital Radiology is designed for a maximum of 21 hours of European
external CME credits. Each medical specialist should claim only those hours of credit that he/she actually
spent in the educational activity.
EACCME credits are recognised by the American Medical Association towards the Physician's Recognition
Award (PRA). To convert EACCME credit to AMA PRA category I credit contact the AMA.
The Post Graduate Course has been approved by the European Accreditation Council for Continuing medical
Education (EACCME) for 15 CME credits.
The 12th European Symposium on Urogenital Radiology has been awarded 20 CME credits by the Medical
Chamber of Slovenia.
The CME credit request should be filled in and returned to the Registration desk at the end of the meeting or
before departure.
7

General Information
ABBREVIATIONS
LECTURE HALLS
MS Members' Session The lectures halls are named as follows:
L Lectures Lecture room 1 First floor
WS Workshop Lecture room 2 First floor
SS Scientific Session Lecture room 3 First floor
P Poster Session Lecture room 4 Ground floor
Y Young Urogenital Radiologists' Forum Lecture room 5 Ground floor
Please see the map of the conference area.
BADGES
It is obligatory for all participants to wear their
badge visibly throughout the meeting as it is the
entrance ticket to all sessions. In case of badge
loss please contact at the Registration Desk.
LIABILITY
The local organisers and ESUR are not liable for
personal injury and loss or damage of private property.
Participants should have their own personal insurance.
BANKS
Banks are usually open from 9.00 –16.00
LUNCHES
Lunches on Friday, Sept 9 and Saturday, Sept 10 are
included in the registration fee. Lunches are served at
the place of the meeting. Please follow the signs and
announcements.
CASH BAR
Outside the official coffee break times
beverages, snacks and food can be purchased
in the restaurant in the ground floor. Please see
the map of the conference area.
POSTER EXHIBITION
Scientific posters are located in the ground floor.
Please refer to the floor plan.
The poster exhibition is open from Thursday 12.00 till
Sunday 12.30.
CERTIFICATE OF ATTENDANCE
The CME credit request should be filled in and
returned at the Registration desk.
A certificate of attendance will be handed out at
the end of the meeting at the Registration desk.
POSTER PRIZES
The three best scientific exhibits will be awarded a
diploma. Evaluation of the posters will be based on
novelty, accuracy, educational value and design.
COFFEE BREAKS
Coffee, beverages, and food will be available for
registered participants during the designed
coffee break times in the exhibition area.
CONFERENCE LANGUAGE
The Symposium is held in English.
CURRENCY
Slovenian tolar (SIT). 1EUR is approximately
240 SIT. Major credit cards are widely accepted.
8

PREVIEW CENTRE
Please follow the signs from the Registration
area.
Opening hours:
Thursday
Friday
Saturday
Sunday
September 8
September 9
September 10
September 11
11.00-17.00
07.30-17.00
07.30-15.00
08.00-12.30
Speakers must deliver their presentations in the
following format: PowerPoint format for PC,
version XP or older, on a CD-ROM or USB to
the Preview Centre at least 90 minutes prior to
the beginning of each session. Technicians will
pre-load the presentation. If you are using
Macintosh please make sure that your
presentation is saved in PC format. If there are
video sequences included in the presentation
please make sure to save the video clip files
onto your CD-ROM.
Please note that your laptop cannot be used for
the presentation in the lecture halls.
REGISTRATION
Registration is possible at the Registration Desk.
Please follow the floor plan.
Opening hours:
Thursday
Friday
Saturday
Sunday
September 8
September 9
September 10
September 11
11.00-17.00
07.30-17.00
07.30-15.00
08.00-12.30
TECHNICAL EXHIBITION
The technical exhibition is located in the loby
outside the main auditorium. Please refer to the
floor plan. The technical exhibition is open from
Friday 8.00 to Sunday 12.00.
YOUNG UROGENITAL RADIOLOGISTS'
FORUM
Young urogenital radiologists are defined as
radiologists in training, or recently accredited
radiologists not older than 35 years. To encourage and
promote research, three best abstracts submitted by a
young urogenital radiologist as the main author will be
honoured and awarded.
9

Map of Ljubljana
1. Grand Hotel Union Executive, Miklosiceva 1, 2. Grand Hotel Union Business, Miklosiceva 3, 3. Grand
Hotel Union Garni, Miklosiceva 9, 4. Hotel Slon-Best Western Premier, Slovenska 34, 5. City Hotel,
Dalmatinova 15, 6. Pension pri Mraku, Rimska cesta 4, 7. Hotel Park, Tabor 9, 8. Faculty of Law,
Poljanski nasip 2
10

Map of the Conference Area
11

Programme Overview
THURSDAY
September 8, 2005
FRIDAY
September 9, 2005
SATURDAY
September 10, 2005
SUNDAY
September 11, 2005
11.00 - 17.00
REGISTRATION
Poster Exhibition
7.30 - 17.00
REGISTRATION
Poster Exhibition
8.00 - 10.00
Lecture I
7.30 - 15.00
REGISTRATION
Poster Exhibition
8.00 - 10.00
Lecture IV
8.30 - 9.30
Lecture VI
9.30 - 11.00
Lecture VII
10.00 - 10.10
Coffee Break
10.00 - 10.15
Coffee Break
11.00 - 11.30
Coffee Break
10.10 - 11.40
Lecture II
MEMBERS' DAY
12.30 - 12.40
Introduction
11.40-11.55
Award Wining Paper from
the Members’ Day
11.55 - 12.25
(Satellite symposium)
10.15 - 11.45
Lecture V
11.45 - 12.45
WS IV, WS V, WS VI
11.30 - 12.30
Contrast Media
Guidelines
12.25-12.40
Opening ceremony
12.40 - 13.20 Lunch
12.40 - 13.50
Scientific presentation 13.20 - 15.20
Lecture III
12.45 - 13.45
Film Reading Session
13.50 - 14.20
Coffee break
15.20 - 15.30
Coffee break
13.45 - 14.15
Lunch
14.20 - 15.20
Scientific presentation
15.20 - 16.30
Scientific presentation
15.30 - 16.30
WS I, WS II, WS III
16.30 - 17.30
SS-1, SS-2, SS-3,
WS VII
14.15 - 15.05
SS-4, SS-5, SS-6
12.30
ESUR Closing
17.00
Bus tour to Radovljica
and Bled
18.00
RadiologARTists’
Exhibition
15.30
Excursion
to Postojna
20.00
MEMBERS' DINNER
(Bled)
19.00/19.30
Walking tour
20.00
WELCOME RECEPTION
(Slovenian Philharmony)
20.30
COURSE DINNER
(Ljubljana Castle)
13

Social Programme and Guided Tours
Thursday, September 8, 2005
Members' Dinner
For ESUR members with accompanying persons only. The Members' Dinner will take place at Bled. Before
dinner a visit to the Museum of Apiculture in Radovljica and a visit to Bled are organised. Price per person:
50/60 EUR
Friday, September 9, 2005
RadiologArtists’ Exhibition Opening
Opening of the RadiologArtists’ Exhibition at the Kodeljevo Castle and lunch are included in the registration
fee and the fee for accompanying persons.
RadiologArtists’ Exhibition
Benedetta Bonichi, Ludvik Tabor, Tomaz Kunst, Maja Parac Kosem, Kajsa Haglund, Bogomir Celcer, Petra
Polajner, Sasa Steparski Dobravec, Lee Talner, Margherita Levo Rosenberg and Mira Pusenjak.
Most authors are radiologists who follow their artistic dream. Those who are not professionally involved with
radiology are artists dealing with the concept of radiology. Artworks range from paintings to photography,
video and even radiography.
Friday, September 9, 2005
Guided city walk
Included in the registration fee is a short sightseeing tour through the old city to the place of the Welcome
Reception.
Friday, September 9, 2005
Opening Ceremony and Welcome Reception
All participants and accompanying persons are invited to the Opening Ceremony in the Slovenian
Philharmony (RadiologARTists’ concert). After the Opening Ceremony there will be a welcome reception.
The reception is included in the registration fee and the fee for accompanying persons.
RadiologARTists’ concert
Lee Talner - viola da gamba
Sven Dorf - violin
Domen Marincic - harpsichord
Saturday, September 10, 2005
Pavel Berden and Vox Medicorum
Aleš Koren and Footprints - blue grass
Lorenzo Derchi - guitar (and Footprints)
Sasa Steparski - coreograpy & ballet - Dance Macabre
Lee Talner - music & photographies
Course Afternoon
All participants and accompanying persons are invited to the Course Afternoon that includes a visit to the
Postojna Caves and a Course Dinner. Price per person: 65/75 EUR.
Saturday, September 10, 2005
Course Dinner
We welcome you to the Course Dinner that will take place at the Ljubljana Castle.
For participants and accompanying persons that will not participate in the Course Afternoon the price per
person is 50/60 EUR.
14

Programme
Thursday, September 8, 2005
MEMBERS' DAY - SCIENTIFIC SESSIONS
(Lecture room 1)
11.00 – 17.00
Registration
Poster Exhibition
12.30 – 16.00
Introduction 12.30 – 12.40
Members’ Session I
Upper Urinary Tract
Moderator: J. O. Barentzs (NL)
12.40 – 13.40
12.40 – 12.50 MS1 In-vivo magnetic resonance imaging of magnetically labelled stem cells in kidneys
after selective intraarterial injection: initial results
Harald Ittrich, Friedrich Thaiss, Claudia Lange, Hannes Dahnke, Gerhard Adam, Claus
Nolte-Ernsting
12.50 – 13.00 MS2 Enhancement of central scar in renal oncocytomas: a new feature
Tourdias T, Grenier N, Cimpéan A, Deminière A, Pérot V.
13.00 – 13.10 MS3 Coronal vs Standard Axial Image Review for CT Urography
Feng FY, Caoili EM, Cohan RH, Al Hawari M, Adusumilli S, Francis IR, Nan B, Zheng, and
Ellis JH
13.10 – 13.20 MS4 Detection of renal perfusion defects in rabbits using non-linear contrast specific mode
with low transmit power imaging and SonoVue
Emilio Quaia, Manuel Belgrano, Salvatore Siracusano, Stefano Ciciliato, Stefano Cernic,
Maria Cova
13.20 – 13.30 MS5 Doppler Ultrasonography of Arterial Stenosis in Renal Transplanted Patients
Gaute Hagen, Jonas Wadström, Anders Magnusson
13.30 – 13.40 MS6 Catheter-based optical coherence tomography of the porcine ureter ex vivo:
morphometric comparison with histology
U.L. Mueller-Lisse, O. A. Meissner, M. Bauer, M. Jaeger, F. Roggel, G. Babaryka, M. Reiser,
U.G. Mueller-Lisse
13.40 – 13.50 MS7 Assessment of diagnostic confidence in renal malignancies diagnosed at contrastenhanced
US
Emilio Quaia, Alessandro Palumbo, Stefania Rossi, Maria Cova
Members’ Session II
Upper Urinary Tract
Moderator: S. Morcos (UK)
13.50-14.20
Coffee break
14.20 – 15.20
14.20 – 14.30 MS8 Diagnostic criteria for acute upper urinary tract obstruction at dynamic MRI
Mohamed Abo El-Ghar, Tarek El-Diasty, Ahmed Shoma, Huda Refaie, Ahmed Shokier
14.30 – 14.40 MS9 Delineation of upper urinary tract segments at low-dose multidetector CT urography:
retrospective comparison with a standard protocol
Mueller-Lisse UG, Meindl T, Coppenrath E, Mueller-Lisse UL, Degenhardt C, Khalil R,
Reiser MF
14.40 – 14.50 MS10 Image-guided peritoneal core biopsy (IGB) in peritoneal carcinomatosis (PC) for
tumour type and patient care: experience in 149 patients.
Kirsty E Anderson, Matthew J Hewitt, Nafisa Wilkinson, Sarah E Swift, Michael Weston,
John A Spencer
15

14.50 – 15.00 MS11 Analysis of errors in ultrasonographic detection and characterisation of renal
tumors
Boris Brkljacic, Igor Cikara, Josip Curic
15.00 – 15.10 MS12 Diagnosis of upper tract transitional cell carcinoma (TCC) with a single phase
multidetector CT urography.
F.Cornud, M.Bienvenu, H.Guerini, X. Poittevin, A.ChevrotT
15.10 – 15.20 MS13 Does a limited CT Urography( CTU) offer important additional information in patients
with haematuria who had normal IVU, Ultrasound and Flexible Cystoscopy?
H S Ganesh, F Salim, S K Moecos
Members’ Session III
Lower Urinary Tract
Moderator: L. Derchi (I)
15.20 – 16.30
15.20 – 15.30 MS14 Ferumoxtran-10 enhanced MR imaging in detection of metastases out of the surgical
view in prostate cancer
R.A.M. Heesakkers, J.A. Witjes, C.A. Hulsbergen- van de Kaa, J.O. Barentsz
15.30 – 15.40 MS15 IMRT boost planning on dominant intraprostatic lesion by means of gold markerbased
3D fusion of CT, 1H spectroscopic and dynamic contrast-enhanced MR
imaging.
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 Kollenburg, Henkjan J. Huisman, J. Alfred Witjes, Jan
Willem Leer, Andries G. Visser, Jelle O. Barentsz
15.40 – 15.50 MS16 The additive effect of contrast agent administration in transrectal ultrasound staging
of prostate cancer
Stijn W.T.P.J. Heijmink, Hilco van Moerkerk, Jurgen J. Fütterer; Christina A. Hulsbergenvan
de Kaa, Ben C. Knipscheer, J. Alfred Witjes, Johan G. Blickman, Jelle O. Barentsz
15.50 – 16.00 MS17 Fast-Track Diagnosis for Macroscopic Hematuria using Same -Day CT Urography &
Flexible Cystoscopy
NC Cowan, JMG Willatt, MH Hawkins, PJS Charlesworth, JP Crew
16.00 – 16.10 MS18 Effect of tadalafil on prostate hemodynamics: preliminary evaluation with contrast
enhanced US
Michele Bertolotto, Gianfranco Savoca, Elena Trincia, Giulio Garaffa, Loretta Calderan,
Maria Assunta Cova
16.10 – 16.20 MS19 Depiction of prostatic zonal anatomy at portovenous multidetector CT
Scherr MK, Nippert A, Reiser MF, Müller-Lisse UG
16.20 – 16.30 MS20 The Urethral Support System as Defined By Phased-Array MRI with Cadaveric
Dissection and Histological Correlation in Nulliparous Female
Rania F. El Sayed, Medhat Morsi Sahar El Mashed, Mohamed S. Abd El Azim
Members’ Dinner – Tour to Bled 17.00
16

Friday, September 9, 2005
07.30 – 17.00
Registration
POSTGRADUATE COURSE:
EMERGENCY UROGENITAL RADIOLOGY
Lecture I Urogenital trauma
Moderators: Y.Narumi (J), G.Gayer (IL)
(Lecture room 1)
08.00 – 10.00 Traumatologist's perspective: M.Cimerman (SI)
Urologist's perspective: M.Mihelic (SI)
Imaging of urogenital trauma
Upper urinary trauma: A.Magnusson (S)
Lower urinary trauma: S.Goldman (USA)
Trauma of male external genitalia: C.Sandler (USA)
10.00 – 10.10
Coffee break
Lecture II
Urinary bleeding
Moderators: M. Collins (UK), J.Hubert (F)
(Lecture room 1)
10.10 – 11.40 Investigation of microscopic hematuria-Nephrologist's
perspective: J.Floege (DK)
Imaging for suspected malignant diseases:
E.Caoili (USA)
Imaging for benign conditions: R.Cohan (USA)
Haemospermia: P.Ramchandani (USA)
Arterial embolisation in emergency uroradiology:
T.El-Diasty (EG)
Award Winning Paper from the Members’ Day (Lecture room 1)
11.40 – 11.55
Satellite symposium
(Lecture room 1)
11.55 – 12.25
Opening ceremony (Lecture room 1)
12.25 – 12.40
Lunch
Lecture III Urinary obstruction
Moderators: F.Frauscher (A), C.Oblak (SI)
12.40 – 13.20 Lunch
(Lecture room 1)
13.20 – 15.20 Urologist's perspective: A.Kmetec (SI)
Imaging and intervention of obstruction
Plain films, i.v.u, and US: G.Heinz-Peer (A)
CT (U) and MRU: J.Kemper (D)
Radiation and economic aspects: F.Stacul (I)
Intervention in obstruction: S.Moussa (UK)
15.20-15.30
Coffee break
17

WORKSHOP I
Ultrasound of kidneys and urinary bladder Hands-on WS
15.30 – 16.30 B.Brkljacic (HR)
P.Pavlica (I)
D.Vidmar (SI)
S.Rainer (SI)
(Lecture room 1)
WORKSHOP II
Interventional radiology
Moderators: P.Bosnjakovic (SCG)
15.30 – 16.30 Embolisation of uterine fibroids: N. Cowan (UK)
Renal tumor ablation: P.Choyke (USA)
WORKSHOP III
Prostatic cancer
Moderators: N.F.Wasserman (USA), N.Grenier (F)
(Lecture room 2)
(Lecture room 3)
15.30 – 16.30 Detection and the role for the radiologist?: R.Oyen (B)
Staging-US or MR?: F.Cornud (F)
New developments: J.Barentsz (NL)
SCIENTIFIC SESSIONS – I, II, III, WS VII 16.30 – 17.30
Scientific Session I
TUMORS/KIDNEY AND COLLECTING SYSTEM
Moderators: M. Marroti (HR), M. Budau (RO)
(Lecture room 1)
16.30 – 16.38 SS1 Multi-detector row CT urography in the investigation of painless hematuria; A. Ch.
Tsili1, C. Tsampoulas, O. Katsios1, D. Giannakis, P. Tzoumis, D. Dristiliaris, N. Sofikitis, S.
C. Efremidis
16.38 – 16.46 SS2 Multiphase Multidetector-Row CT (MDCT) of Transitional Cell Carcinoma of the Renal
Pelvis and the Ureter: Improved Detection, Diagnosis and Staging; Gerald A. Fritz,
Helmut Schoellnast, Hannes A. Deutschmann, Martin Wehrschuetz, Manfred Tillich
16.46 – 16.54 SS3 Patients at high risk of upper tract urothelial cancer: evaluation of hydronephrosis
using high-resolution magnetic resonance urography; Rohit Chahal, Kathryn Taylor,
Ian Eardley, Stuart N Lloyd, John A Spencer
16.54 – 17.02 SS4 Pheochromocytoma: a retrospective review of 27 cases with their histopathologic
correlation; Dogra VS, Bhatt S, Novak R, Martin C, MacLennan G
17.02 – 17.10 SS5 Evaluation of focal renal lesions with contrast enhanced ultrasonography (CEUS)
using a new microbubble contrast agent (SonoVue®); Pallwein L., Frauscher F.,
Neururer R., Georg B., Klauser A, Gradl H., Schurich M.
17.10 – 17.18 SS6 Multi-detector row CT cystoscopy in the assessment of urinary bladder tumors; A.
Ch. Tsili, C. Tsampoulas, O. Katsios, P. Champilomatis, P. Tzoumis, N. Chatziparaskevas,
N. Sofikitis, S. C. Efremidis
17.18 – 17.26 SS7 Preoperative MSCT imaging of venous spread of renal cell carcinoma (RCC);
Stern-Padovan R, Perkov D, Smiljanic R, Oberman B, Lusic M, Marinic J.
Scientific Session II
LOWER UROGENITAL TRACT
Moderators: I.Requejo Isidro (E), B.Brkljacic (HR)
(Lecture room 2)
16.30 – 16.38 SS 8 Evaluation of Varicocele Incidence of Paraplegic Patients by Colour Doppler
Ultrasonography; A. Unsal, B. Yilmaz, A. T. Turgut, C. Z. Karaman,
R. Alaca
18

16.38 – 16.46 SS 9 Resistivity and Pulsatility Index Alteration in Subcapsular Branches of Testicular
Artery: Indicator of Impaired Testicular Microcirculation in Clinical Varicocele? ; A.
Unsal, A. T. Turgut, F. Taskin, C. Z. Karaman
16.46 – 16.54 SS 10 The reliability of ultrasonography in the evaluation of acute scrotal pain;
Lyssiotis Ph., Constantinidis F., Alivisatos G, Anastopoulos I, Liakouras Ch., Tsines G.,
Tavernaraki K., Malahias G.
16.54 – 17.02 SS11 Chronic constipation is a significant factor for the etiopathogenesis of varicocele; A.
T. Turgut, E. Ozden, P. Kosar, U. Kosar, B. Cakal, A. Karabulut
17.02 – 17.10 SS12 Voiding Urosonography in the era of second generation ultrasound contrast agents;
A.Anthopoulou, J.Tzovara, E.Siomou, A.Fotopoulos, E.Arkoumani, F.Katzioti,
F.Papadopoulou
17.10 – 17.18 SS13 Voiding Urosonography combined with Fluoroscopic Voiding Cystourethrography in
the diagnosis of reflux: Does the order matter?; A.Anthopoulou, F.Papadopoulou,
J.Tzovara, E.Siomou, E.Arkoumani, F.Katzioti, S.Efremidis
17.18 – 17.26 SS14 Effect of premicturitional bladder volume on accuracy of postvoid residual urine
volume measurements; Bladder fullness rate is of great importance for preventing
false positive residue diagnosis; Eriz Özden, Ahmet Tuncay Turgut, Çađatay Göđüţ,
Uđur Koţar, Sümer Baltacý
Scientific Session III
BENIGN UROGENITAL EMERGENCIES
Moderators: J.A.W. Webb (UK), V.M. Builov (RUS)
(Lecture room 3)
16.30 – 16.38 SS15 From IVU to Unenhanced CT: Modernising the Imaging of Acute Renal Colic; Arvind
Pallan, J. Graham Young, Paul Crowe, Rajesh Patel, Linda Freeman, Sean Morris
16.38 – 16.46 SS16 Emergency non traumatic urogenital imaging. What happens when CT is not
available?; Demosthenes D Cokkinos, Elissavet Protopapa, Nikolaos Sakaridis, Ioanna
Papaconstantinou, Styliani Giannou
16.46 – 16.54 SS17 Renal Injuries - Diagnostic Evaluation by Sonography; Dubravka Vidmar
16.54 – 17.02 SS18 CT imaging of iatrogenic urinary lesions after urologic, gynecologic, and obstetric
procedures; Hrabak M, Stern-Padovan R, Smiljanic R, Perkov D, Lusic M.
17.02 – 17.10 SS19 Retrospective analysis of ureteral distension as function of delay time after i.v.
contrast-media injection followed by i.v. saline infusion in CT-Urography; T Meindl, E
Coppenrath, C Degenhardt, UL Müller-Lisse, M Reiser, UG Müller-Lisse
17.10 – 17.18 SS20 Contrast enhanced magnetic resonance urography(MRU) versus excretory
urography(EU) in non dilated upper urinary tract; M.Abd EL-Baky, T.EL-Diasty,
A.Farouk, O.Mansour
16.18 – 17.26 SS21 Computed tomography angiography of haemodialysis arteriovenous fistulae: Impact
of 3D image reconstructions in complicated clinical cases; Dimopoulou A., Claesson
K., Raland H., Wikström B and Magnusson A
WORKSHOP VII
Technical protocols for male and female MRI of the pelvis
Moderators: R.Berkenblit (USA), M.Glusic (SI)
(Lecture room 4)
16.30 – 17.30 MRI of the pelvis in males: U.G.Müller-Lisse (D)
MRI of the pelvis in females: K.Kinkel (CH)
RadiologARTists’ Exhibition - Castle Kodeljevo 18.00
19

Sightseeing / Walking tour Ljubljana 19.00 /19.30
Welcome Reception / Concert - Slovenian Philharmony 20.00
Saturday, September 10, 2005
07.30 – 15.00
Registration
Lecture IV
Urogenital emergencies in the female patient
Moderators: K.Togashi (J),
08.00 – 10.00 Obstetric aspect: T.Premru Srsen (SI)
Gynaecologic aspect: A.Lukanovic (SI)
Imaging of obstetrical and puerperal emergencies:
Jo Mc Hugo (UK)
Embolisation of post-partum bleeding: A.Maubon (F)
Imaging assessment of gynaecological emergencies: G.Serafini (I)
(Lecture room 1)
10.00 – 10.15
Coffee break
Lecture V
Preoperative assessment of benign diseases of the female pelvis
Moderators: K.Sugimura (J), S. Kupesic (HR)
10.15 – 11.45 Endometriosis: K.Kinkel (CH)
Uterine diseases: N.Cowan (UK)
Adnexal diseases: I.Imaoka (J)
Pelvic floor dysfunction: C.Roy (F)
WORKSHOP IV
Female oncologic imaging
Moderators: T.M.Cunha (P), A.Bergman (S)
(Lecture room 1)
(Lecture room 1)
11.45 – 12.45 Cervical cancer staging-MRI, CT, PET?: C.Balleyguier (F)
What to do with suspicious adnexal mass at US?: K.Togashi (J)
Endometrial cancer: J.Spencer (UK)
WORKSHOP V
Pediatric urologic emergencies
Moderator: Z.Zupancic (SI), I.Cvitkovic Kuzmic (HR)
(Lecture room 2)
11.45 – 12.45 Imaging in acute uro-genital trauma, testicular and ovarian torsion:
M.Riccabona (A)
Imaging in acute pediatric urinary tract infections:
K.Darge (D)
Neonatal urinary tract emergencies: J.G.Blickman (NL)
WORKSHOP VI
Upper urinary cancer
Moderators: U.L.Müller-Lisse (D), R.G.Figueiras (E)
(Lecture room 3)
11.45 – 12.45 Kidneys: R.Pozzi-Mucelli (I)
Adrenals: G.Krestin (NL)
Lymphnodes: J.Barentsz (NL)
20

FILM READING SESSION
Moderator: L.Derchi (I)
Lunch
Session IV
TUMORS/PROSTATE
Moderators: R.Stern Padovan (HR), M.Cova (I)
12.45 – 13.45
(Lecture room 1)
13.45 - 14.15 Lunch
(Lecture room 1)
14.15 – 14.23 SS22 3T endorectal MR imaging in localizing and staging prostate cancer using
gadolinium-enhanced FLASH3D subtraction technique; Jurgen J. Futterer, Stijn
W.T.P.J. Heijmink, Tom W.J. Scheenen, Christina A. Hulsbergen-van der Kaa, J. Alfred
Witjes, Jelle O. Barentsz
14.23 – 14.31 SS23 Contrast-enhanced transrectal color doppler ultrasound for assessment of
tumorangiogenesis in prostate cancer; Schurich M., Frauscher F., Klauser A., Pallwein
L., Strohmeyer D., Bartsch G.
14.31 – 14.39 SS24 A prospective randomized trial comparing contrast-enhanced targeted versus
systematic ultrasound guided biopsies: impact on prostate cancer detection;
Frauscher F. Pelzer A., Berger A., Halpern E., Pallwein L., Klauser A., Gradl H., Bartsch G.
14.39 – 14.47 SS25 Comparison of Contrast-enhanced Color Doppler Targeted Biopsy with Systematic
Biopsy: Impact on Prostate Cancer Detection in Men with PSA between 4 to 10; Leo
Pallwein, Andrea Klauser, Ethan Halpern, Alexander Pelzer, Dieter Zur Nedden
14.47 – 14.55 SS26 Dutasteride Prior Prostate Biopsy Increases Prostate Cancer Detection; Andrea
Klauser, Andreas Berger, Ethan Halpern, Leo Pallwein, Ammar Mallouhi, et all
14.55 – 15.03 SS27 A comparison of MR image quality and accuracies of localization and staging of
prostate cancer between a body array and endorectal coil at 3T; Stijn W.T.P.J.
Heijmink, Jurgen J. Fütterer, Tom W.J. Scheenen, Christina A. Hulsbergen-v.d. Kaa, Ben
C. Knipscheer, J. Alfred Witjes, Johan G. Blickman, Jelle O. Barentsz
Session V
FEMALE MISCELANEOUS
Moderators: S.Dorf (DK)
(Lecture room 1)
14.15 – 14.23 SS28 16-slice multidetector CT and MRI in the detection and characterization of ovarian
masses; A. Ch. Tsili, C. Tsampoulas, O. Katsios, K. Vlachos, Ev. Paraskevaidis, S. C.
Efremidis.
14.23 – 14.31 SS29 Bone lesions as a complication of the treatment of gynecologic malignancies - A
great mimicker; S. Lima, A. Félix, T.M. Cunha
14.31 – 14.39 SS30 Ultrasound-guided Transurethral Injection of Adult Stem Cells for Treatment of
Urinary Incontinence; Andrea Klauser, Dieter Zur Nedden, Leo Pallwein, Rainer
Marksteiner, Hannes Strasser
14.39 – 14.47 SS31 Hysterosalpingograhy vs laparascopy in the assessment of infertile women; Eda
Vrtacnik Bokal, Sara Korošec, Helena Ban
14.47 – 14.55 SS32 The role of transvaginal sonography in detection of congenital uterine
malformations; Martina Ribic-Pucelj
Session VI
RENAL PERFUSION, TRANSPLANTATION AND INTERVENTION
Moderators: M.Hellstrom (S)
(Lecture room 1)
14.15 – 14.23 SS33 Effective EndoUro-Radiological Conferences: a model for success; M.C.Collins
F.Salim L.Hawksworth J.Hall K.J.Hastie
14.23 – 14.31 SS34 Split renal function in patients with suspected renal artery stenosis – a comparison
between gamma camera renography and two methods of measurement with
computed tomography; Henrik Björkman, Hampus Eklöf, Jonas Wadström, Lars-Göran
Andersson, Rickard Nyman, Anders Magnusson
21

14.31 – 14.39 SS35 Measuring split renal function in renal donors: can computed tomography replace
renography?; Henrik Björkman, Jonas Wadström, Lars-Göran Andersson, Hans Raland,
Anders Magnusson
14.39 – 14.47 SS36 MR imaging in diagnosis of post-renal transplant complications; T. EL-Diasty, M.
Attia, A. Youssef, U. Galal, F. Tantawy
14.47 – 14.55 SS37 Quantitative T1-perfusion and renal MRAngiography: a noninvasive all-in-one
approach for renovascular evaluation; M. Dujardin, S. Sourbron, R. Luypaert, P. Van,
Schuerbeek, S. Makkat, F. Deridder, P. Van der Niepen, D. Verbeelen, T. Stadnik
14.55 – 15.03 SS38 Changes in renal blood flow related to extracorporeal shock wave lithotripsy
measured by FLASHSTAR; Eva Pallwein, Leo Pallwein, Christian Kremser, Werner
Judmaier, Günther Janetschek, Ferdinand Frauscher, and Michael Schocke
Excursion to Postojna Caves 15.30
Course Dinner – Ljubljana Castle 20.30
Sunday, September 11, 2005
Lecture VI
Urinary infections
Moderators: R.Katz (IL), F.Danza (I)
08.30 – 12.30
Registration
(Lecture room 1)
08.30 – 09.30 Nefrologist' s perspective: A. Bren (SI)
Imaging
Pyogenic infections: T.Gokan (J)
TB and uncommon infection of urogenital tract:
T.El-Diasty (EG)
Lecture VII
Acute renal failure and emergencies in the kidney transplant
Moderators: S.Hanna (EG), M.Prokop (NL)
(Lecture room 1)
09.30 – 11.00 Clinical evaluation of acute renal failure: R. Ponikvar (SI)
Clinical evaluation of emergencies in the kidney transplant:
M.Malovrh (SI)
Imaging evaluation
Native kidneys: O.Helenon (F)
Transplanted kidneys - renal emergencies: J.Jakobsen (N)
Transplanted kidneys - extrarenal emergencies: N.Grenier (F)
11.00 – 11.30
Coffee break
CONTRAST MEDIA GUIDELINES
Moderator: M.F.Bellin (F)
(Lecture room 1)
11.30 – 12.30 Effects of CM on haematology (ESUR guideline):
P.Aspelin (S)
Use of contrast media in the emergency room: J.Ellis (USA)
Contrast Medium induced nephrotopathy-current guidelines:
H.S.Thomsen (DK)
ESUR Closing (Lecture room 1)
12.30 – 12.45
22

POSTER SESSION
P1
P2
P3
P4
P5
P6
Low field open MRI of the adrenal glands: a pictorial essay; Robert Berkenblit
Multicystic dysplastic kidney - an audit of 15 years of experience in Plymouth, UK, 1990-2004; Narayanaswamy S, Jones R
Fat is the key; R García Figueiras, C Villalba Martín, A García Figueiras, M Otero Echart, G Pazos, L Oleaga, I Requejo
Massive pleural effusion as the first manifestation of renal cell carcinoma - a case report; Mojca Juvan-Zavbi
MR urography of obstructive uropathy: diagnostic value of the method in selected clinical groups; Joanna Zielonko
Multi-detector row CT in the evaluation of renal masses; AC Tsili, C Tsampoulas, O Katsios, T Vadivoulis, D Baltogiannis, N
Sofikitis, SC Efremidis
P7 Sonographic detection of renal and ureteral calculi - diagnostic accuracy of the twinkle sign; Pallwein L, Frauscher F,
Andrea K, Gradl H, Schurich M, Struve P, Peschel R, Bartsch G
P8
P9
P10
P11
P12
P13
Contrast enhanced ultrasound in the evaluation of renal trauma; Regine G, Atzori M, Buffa V, Galluzzo M, Miele V, Adami L
Spiral CT evaluation of nontraumatic haemorrhage of adrenals` adenoma; Patelis E, Tavernaraki K, Constantinidis F, Alexiou
K, Panagiotakopoulou A, Antonopoulos P
Retained calculi and complications of extracorporeal shock wave lithotripsy: evaluation with helical computed
tomography; Patelis E, Tavernaraki K, Kedri K, Georgoulis P, Petroulakis A, Antonopoulos P
Spontaneous rupture of renal cell carcinoma; Pertia N, Khutulashvili N, Phachuashvili M
Colic pain in patients with hyperechoic US appearance of renal medulla; Manavis J, Deftereos S
Bilateral tuberculosis infection of adrenal glands: utility of CT-guided biopsy in diagnosis; Kalogeropoulou CP, Liatsikos EN,
Papathanassiou ZG, TsotaT Petsas I
P14 The role of spiral CT in the investigation and diagnosis of pyelonephritis; Patelis E, Dalamarinis K, Constantinidis F,
Tavernaraki K, Constantinidou E, Antonopoulos P
P15
P16
YP17
P18
P19
P20
P21
P22
P23
P24
P25
P26
Acute pyelonephritis: comparison of diagnosis with CT and contrast-enhanced US; Andrea Klauser, Leo Pallwein, Andreas
Berger, Ammar Mallouhi, Dieter Zur Nedden
Evaluation of cystic renal masses: comparison of CT and contrast enhanced US by using the Bosniak classification
system
Michele Bertolotto, Libero Barozzi, Stefania Gava, Loretta Calderan, Anna Tiberio, Maria Assunta Cova
Large adrenocortical oncocytoma: case report; Nasr El-Tabey, Essam Abou-Bieh, Ahmed Farouk, Ibrahim Eraky
CT-urography (CTU) added on to CT of the abdomen: retrospective comparison of standard-dose and low-dose CTU
protocols; Meindl T, Coppenrath E, Mueller-Lisse UL, Degenhart C, Reiser MF, Mueller-Lisse UG
Incidentally discovered urinary and nonurinary lesions by multidetector noncontrast CT for flank pain; Huda Refaie,
Ahmed Shokier
The benefit of contrast-enhanced ultrasound in the diagnosis of renal tumors (preliminary results); Irena Sedonja,
Marija Santl Letonja
Evaluation of blunt traumatic bladder rupture by CT cystography; Luana Stanescu, Joel Gross, Hunter Wessells,
Emily Meshberg, Lee Talner
Misleading gastrointestinal symptoms in renal carcinoma patients; Marija Frkovic, Marijan Frkovic, Ivan Kos, Marko Kralik,
Dobrila Tomic
Colour doppler ultrasound assessment of the inferior vena cava in patients with renal cell carcinoma Correlation with
intra-operative findings; Mojca Glusic, Bojana Cernelc, Miro Mihelic
Complications of renal transplantation: emergent imaging evaluation; Navalho M, Mascarenhas V, Vitor L, Tavora I
Is the radiation dose increasing in uroradiology?; Pär Dahlman, Lars Jangland, Anders Magnusson
Imaging findings in urethra posterior injuries; Requejo I, Fernández P, Fernández L, Méndez C, Crespo C, Ponce J
23

P27
P28
P29
P30
Integrated imaging in the evaluation of renal post-transplantation complications; M Atzori, G Regine, De Paulis P, A Cortese,
L Adami
Testicular masses in association with congenital adrenal hyperplasia: MR features compared with sonographic findings;
Suliman HM, Stikkelbroeck NMML, Jager GJ, Blickman JG, Otten BJ, Hermus ARMM
Testicular torsion - diagnosis by colour duplex sonography; Dubravka Vidmar, Alenka Visnar Perovic
The effect of external scrotal cooling on the viability of the torsed testis in rats; Mahmoud Haj, Haim Farhadian,
Norman Loberant, Shaul Shasha
P31 Imaging findings of complications of prostate cancer therapy; Requejo I, Seoane M, Gulias D, Fernandez P,
Garcia Figueiras R, Crespo C
P32
P33
P34
P35
Is antibiotic prophylaxis necessary before TRUS guided transrectal prostate biopsies? Results of urine and blood cultures
of patients who have undergone prostate biopsy without antibiotic prophylaxis; Tansel Inal, Eriz Ozden,
Ahmet Tuncay Turgut, Murat Çilođlu, Sadettin Küpeli
Illustration of TRUS findings of benign peripheral zone lesions which mimic prostate cancer sonographically;
Ozden E, Tuncay Turgut A, Türkölmez K, Erdođan O, Baltacý S
Imaging findings of ureteroceles; Ozden E, Tuncay Turgut A, Demirel C, Soygür T, Arýkan N
Intratesticuler varicocele; Özden E, Tuncay Turgut A, Süer E, Yaman Ö
P36 The evaluation of the efficiency of periprostatic nerve blockade in TRUS guided repeat biopsies; Özden E, Tuncay Turgut A,
Göđüţ C, Özayar A, Baltacý S
P37
Evaluation of the cause of patient discomfort during TRUS guided prostate biopsy by the comparison of the effect of
periprostatic nerve blockade on pain due to probe insertion and on pain related with the penetration by the biopsy needle;
Ozden E, Tuncay Turgut A, Göđüţ C, Kutman K, Anafarta K
P38 MSCT evaluation of emergency patients with palpable abdominal mass detected after delivery; Roglic A,1 Stern-Padovan R,
Mokos I, Kralik M
YP39
Combined imaging approach in staging urinary bladder cancer; Abou-Bieh E, Barentsz J, Salah Wadee B, Eldiasty TA
YP40 Post-contrast gradient T1WI: Has a role in patient with urinary bladder carcinoma or not; Abou-Bieh E, Barentsz J,
El-Diasty T
P41 MR imaging in the histologic characterization of testicular tumors; Tsili AC, Tsampoulas C, Katsios O, Vadivoulis T,
Pappas A, Sofikitis N, Efremidis SC
P42 Case report: presentation of splenogonadal fusion, a rare deformity; Lyssiotis P, Constantinidis F, Anastopoulos I,
Liakouras C, Tsines G, Kalikatzaros E, Malahias G
P43 Magnetic resonance imaging of normal and benign conditions of the urinary bladder; Manavis J, Kaldoudi E, Antoniou P,
Deftereos S, Touloupidis S
P44
P45
P46
P47
P48
P49
P50
P51
P52
P53
Imaging of urinary bladder hernias; Bacigalupo LE, Bertolotto, Barbiera, Pavlica P, Lagalla R, Pozzi Mucelli RS, Derchi LE
Calculosis of the urethra as a consequence of congenital anomalies of the urinary tract; Zupancic Z, Babnik Peskar D
Novel nurse led prostate biopsy service; Moussa SA, Innes A, Davis G
MRI findings of pure adenomyosis of uterus after uterine artery embolization; Sang-Woon Yoon, Ki Whang Kim,
Myeong-Jin Kim
Prevalence of ovarian adrenal rest tumours and polycystic ovaries in females with congenital adrenal hyperplasia: results
of ultrasonography and MRI imaging; Suliman HM, Stikkelbroeck NMML, Braat DDM, Jager GJ, Otten BJ
Spectrum of findings in vaginal pathology - usual and unusual manifestations on MRI; Cunha TM, Félix A
Müllerian duct anomalies: a radiologic and clinical overview: Souto M, Egas Moniz H, Felix A, Cunha TM
Uterine sarcomas: a retrospective study; Costa N, Félix A, Cunha TM
Spectrum of MRI findings in endometriosis; Oleaga L, Isusi M, García Figueiras R, De la Rosa J, Ibáńez T, Grande D
Spectrum of MRI findings in adenomyosis; Oleaga L, Isusi M, García Figueiras R, Ibáńez T, De la Rosa J, Grande D
24

P54 Multi-detector row CT in the detection and characterization of adnexal masses; Tsili AC, Tsampoulas C, Katsios O,
Vlachos K, Paraskevaidis E, Efremidis SC
P55
P56
P57
Spectrum of imaging findings in the normal and pathologic endometrium; Pereira I, Félix A, Cunha TM
Adnexal lesions with suspicious criteria for malignancy by MRI; Guerra A, Felix A, Cunha TM
Transvaginal ultrasound versus hysterosonography in the assessment of depth in submucosal uterine fibroids and other
benign lesions of the endometrium; Serafini G, Prefumo F, Dibilio D, Gandolfo N, Derchi L
P58 Ultrasound and MRI imaging of palpable nodularities of the abdominal wall with postpartum onset; Serafini G, Prefumo F,
Ciangherotti F, Gandolfo N, Derchi L
P59 Tumors and tumor – like pelvic lesions: pitfalls and differential diagnosis on CT and MR imaging; Stern Padovan R,
Kralik M, Lucic M, Corusic A
P60
P61
P 62
P63
P64
P65
P66
YP67
Hematocolpos: Clinical presentation and imaging; Loberant N, Herskovits M, Goldfeld M, Salamon V
Emergency ultrasonography in gynecologic field; Jongchul Kim
Percutaneous drainage of kidney abscesses; Mylona S, Kokkinaki A, Thanos L, Stroumpouli E, Karahaliou E, Batakis N
Re-audit of follow-up in patients with impaired renal function undergoing vascular imaging using contrast media;
HJ Harris, S Agarwal, PWG Brown
Renal cell carcinoma (RCC): is radiofrequency ablation (RFA) an effective means of treatment?
Thanos L, Mylona S, Ntai S, Kokkinaki A, Tzavoulis D, Batakis N
Percutaneous CT-guided nephrostomy: a quick and safe method which involves no radiation for the interventional
radiologist; Thanos L, Stroumpouli E, Mylona S, Ntai S, Tzavoulis D, Batakis N
Role of multislice CT scan in evaluation of living renal transplant donors; S Hanna, S Abd El-Rahman, M Shahin & H Badawy
Post-traumatic high-flow priapism: diagnosis with MRA and treatment by selective arterial microcoil embolization (case
report); Ahmed Farouk, Essam Abou-Bieh, Mohamed Abou El-Ghar, Yasser Osman, Tarek El-diasty
P68 MSCT imaging of early and late complications after renal transplantation; Lusic M, Stern-Padovan R, Hrabak M, Sjekavica I,
Molnar M, Oberman B
P69
P70
P71
Pelvo-calyceal biomodelling as an aid to achieving optimal access in percutaneous nephrolithotomy;
Radecka E, Brehmer M, Magnusson P, Palm G Magnusson A
Complications to double J-stents; Radecka E, Holmgren K, Magnusson A
Percutaneous insertion of double-J endoprothesis in children with ureteral stenosis or occlusions; D Kljucevsek,
T Kljucevsek, B Trsinar
25

COURSE LECTURES
UROGENITAL TRAUMA: A TRAUMATOLOGIST’S PERSPECTIVE
Matej Cimerman, Matej Jezernik
University Clinical Centre Ljubljana, Dept. for Traumatology
The traumatologist (or trauma surgeon) in Slovenia is a general surgeon with special training in trauma
surgery. He treats mostly musculoskeletal injuries and leads the trauma team in the management of multiple
injured (polytraumatized) patients. Our trauma surgeon differs from the same profile in the USA and some
European countries. The same system as in Slovenia is known in Germany, Austria, the Chech Republic and
some other European countries. At our institution, isolated urogenital trauma is treated mostly by the
consulting urologist. The traumatologist who sees the patient first, usually begins with the diagnostics and
makes the first working diagnosis. A different problem is presented by urogenital trauma as a part of the
polytraumatized patient. Pelvic injuries are very common in such patients. In these cases, urogenital trauma
is usually associated with pelvic fractures and disruptions. In the study of Bruce et al. (2005), the average
Injury Severity Score (ISS) of patients with extraperitoneal bladder rupture was 41.7, with intraperitoneal
rupture 37.3, and with injured urethra 24.6, which in practice means, that the average patient with urogenital
trauma is really polytraumatized.
In modern traumatology, polytrauma means a syndrome of multiple injuries (ISS>17) with sequential
systemic reactions which may lead to dysfunction of remote organs which were not directly injured (Trentz,
2000). So, polytrauma does not mean just the sum of multiple injuries, but should be regarded as an acute
systemic surgical illness. Polytrauma is always caused by high energy (velocity) and is the number one
cause of death or disability among the active population worldwide. Modern treatment of multiple injured
patients should be active, multidisciplinary and should follow algorithms. The positive impact of such
treatment philosophy was clearly shown (Regel et al., 1991). On the other hand, it is difficult to introduce the
universal algorithm which could be generally accepted worldwide. The protocols should be tailored to the
individual institution respecting all the logistic possibilities. If multislice CT scan is available in the emergency
room, the standard diagnostic protocol can be changed appropriately. In the acute period, where the only
goal is survival the most essential issue is decompression of the body cavities (tension pneumothorax,
cardiac tamponade) and of course effective hemorrhage control. In almost half of such cases, fractures of the
pelvis contribute significantly to severe bleeding. The mortality rate of such patients is high, namely around
50% (Eastridge et al. 2002). At our institution we use a standard polytrauma protocol which is expanded for
»complex pelvic fractures« (Pohlemann 2000). After resuscitation, the basic diagnostics are done. Other
sources of bleeding should be excluded. If the unstable hemodynamics comes from a pelvic instability
emergency stabilization of the pelvis is performed immediately. C-clamp or external fixatior should be used. If
the patient remains hemodynamically unstable, pelvic packing and/or emergency arteriography with
embolization is performed. The definitive reduction and stabilization of the pelvic ring is performed later,
usually after 5 to 10 days (the so called window of opportunity, Trentz 2000).
The biomechanic role of the pelvis is transfer of body weight from the lower extremities to the axial skeleton.
The majority of the forces are transferred via the posterior pelvic ring, and just about one forth via the anterior
pelvic ring. The border is the line which connects both acetabuli. The important role of the pelvis is also the
protection of the intrapelvic organs. The forces which interrupt the pelvic ring can harm these organs, as for
example the urethra and bladder. Pelvic fractures and disruptions can be divided according to stability. This
is the so called Tile’s classification which is used worldwide (Tile 1988). “A” type fractures represent stable
fractures. The transfer of the load from the lower extremities to the axial skeleton is not disturbed. In practice,
“A” type injuries are abruptions of bony parts of the pelvis or fractures of the upper part of the ala. In “B” type
injuries, the pelvic ring is open or compressed, but the posterior part is still able to transfer forces to the axial
skeleton. In »open book« injuries, for example, the SI joint is opened anteriorly, but the strong posterior
sacroiliac ligaments are intact, which enables transfer of the forces to the spine. “C” type injuries are
completely unstable. The pelvic ring is interrupted anteriorly and posteriorly. This classification is logic and
serves as a base for operative decision making. “A” injuries have a better prognosis than “B” and “C” types
26

and are treated mostly conservatively. “B” injuries are treated conservatively and operatively, while “C” type
injuries are treated mostly operatively. The amount of forces which act on the pelvis are also correlated with
this classification, “A” being the least and “C” the most. The only lack of this classification is that the direction
of forces and dislocation cannot be predicted. Burgess combined Tile’s classification with direction of forces.
Every type of Tile`s classification (A,B and C) is subdivided according to anterio-posterior compression
(APC), lateral compression (LC), vertical shear (VS) or combined forces (C) (Burgess AR et al., 1990). For
example, “C” type injuries caused by APC forces are most dangerous for fatal bleeding. We can assume
from this classification that “B” and especially “C” type injuries are most likely associated with urogenital
trauma, while “A” type injuries and isolated acetabular injuries are almost never associated with it. The
probability of bladder injury is correlated with symphisiolysis (AiharaR et al., 2002). The probability of urethral
injuries is correlated with fractures of the pubic rami as well.
The emergency diagnosis of pelvic fractures or disruptions is made by plain x-ray (A-P view). This view is in
most cases enough to understand the basic type of fracture and for emergency planning. For definitive
operative treatment, a CT scan with 3D reconstruction is mandatory. Inspection and palpation of the
anorectal region should be a routine procedure for this type of injuries. In the emergency room, the basic
urologic diagnostics should be done. With gross hematuria, retrograde urethrography is followed by
cistography. If there is blood at the maetus the folley catheteher should not be inserted. After the emergency
diagnostics, we discuss with the urologist about the optimal treatment modality. In polytraumatized patients
who are unstable, damage control procedures are advisable. With damage control procedures we protect the
organs with minimal additional surgical trauma. Of course, damage control procedures are not definitive and
should be followed by second look operations. In the case of urogenital trauma, the most common damage
control procedure is suprapubic cistostomy. If revision of the ruptured bladder is mandatory, it can be
combined with reconstruction of the anterior pelvic ring. The decision making is individual and depends on
the general condition of the patient and local circumstances.
Isolated urogenital trauma should be treated by the urologist. A specific problem is urogenital trauma as an
associated injury of the polytraumatized patient. Management of the polytraumatized patient is
multidisciplinary and in the case of urogenital trauma, the urologist and radiologist skilled in urologic
diagnostics are the members of the trauma management team. Diagnostics should follow the polytrauma
protocol. Treatment of urogenital injuries depends on the general conditions of the polytraumatized patients
and should be tailored individually. The damage control concept can be very helpful with definitive
management when the patient is stable, usually in the window of opportunity after 5 -10 days.
References:
Aihara R et al. Fracture locations influence the likelihood of rectal and lower urinary tract injuries in patients sustaining pelvic fractures. J
Trauma 2002; 52: 205-9.
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.
Burgess AR et al. Pelvic ring disruptions: effective classification system and treatment protocols. J Trauma 1990; 7: 848-56.
Eastridge BJ, Starr A, Minei JP, O`Keefe GJ, Scalea TM. The importance of fracture pattern in guiding therapeutic decision-making in
patients with hemorrhagic shock and pelvic ring disruptions. J Trauma 2002;3:446-50.
Pohlemann T. Pelvic ring injuries: assessment and concepts of surgical management. In: Ruedi TP, Murphy WM eds. AO principles of
fracture management. Stuttgart, New York: Thieme, 2000: 391-413.
Regel G et al. Results of treatment of polytraumatited patients. A comparative analysisi of 3406 cases between 1972 and 1991.
Unfallchirurg 1993; 7: 350-62.
Tile M. Pelvic ring fractures: Should they be fixed? JBJS 1988; 70B: 1-12.
Trentz OL. Polytrauma: pathophysilogy, priorities, and mamagement. In: Ruedi TP, Murphy WM eds. AO principles of fracture management.
Stuttgart, New York: Thieme, 2000: 661-73.
27

GENITOURINARY TRAUMA: UROLOGISTS' PERSPECTIVE
Miro Mihelic
Urologic Department, University Medical Center Ljubljana, Slovenia
Abstract
Rarely, upper and lower urinary tract trauma is presented solely or directly to the urologist. In our country,
even genital trauma is often first presented to the trauma surgeon. Controversies and dilemmas about proper
initial investigation and treatment on admission to the emergency unit lead to review of the current concepts
of initial imaging and management, which the trauma surgeon and urologist should follow to avoid
malpractice and late complications. The urologist's perspective should be to optimize imaging to save time
and get as much information as possible when emergency treatment is needed. The European and American
policy of treatment, the expectations of the clinician, and treatment outcome are discussed in this article.
Introduction
Trauma is the leading cause of death for people between age 1 and 37 years. After the initial evaluation, and
resuscitation of the injured patient done by the anesthesiologist and trauma surgeon other specialists are
attracted to work in a team. The genitourinary tract is involved in approximately 10% of injuries, the kidneys
being the most commonly injured organ.
RENAL TRAUMA
Renal trauma represents 1-5% of all traumas (1). This most commonly injured urogenital and abdominal
organ can produce a life threatening situation, but usually the injury is mild and managed conservatively. The
male to female ratio is 3:1 (2).
As a mechanism of injury, blunt renal trauma represents 80% (urban settings) to 90-95% (rural settings)
(3,4). It is usually secondary to motor vehicle accidents, falls, contact sports and assaults. Traffic accidents
represent almost half of blunt renal injuries. Renal lacerations and vascular injuries represent 10-15% of
blunt renal injuries (5). It is supposed that bending of the supple organ with the applied force represents
stress especially at the periphery of the organ. Renal artery injuries are associated with rapid deceleration.
Traction on the artery with tear of the less elastic intima may lead to thrombosis (6). Renal injuries from
penetrating trauma are less predictable as we are dealing with kinetic energy.
The classification of renal injuries should help in patient's grouping, selecting appropriate therapy and
predicting results. The American Association of the Surgery of Trauma’s (AAST) renal injury scaling system
seems to be the most useful at the moment (7, Table 1)
Table 1: AAST renal injury grading scale.
Grade
Description of injury
1 Contusion or non-expanding subcapsular haematoma
No laceration
2 Non-expanding perirenal haematoma
Cortical laceration < 1 cm deep without extravasation
3 Cortical laceration > 1 cm without urinary extravasation
4 Laceration: through corticomedullary junction into collecting system
Or
Vascular: segmental renal artery or vein injury with contained haematoma
5 Laceration: shattered kidney
Or
Vascular: renal pedicle injury or avulsion
28

To classify the injury, abdominal computed tomography (CT) or direct renal exploration is used. It allows
predicting removal or kidney repair (8).
Indicators of major renal trauma are a rapid deceleration event or direct blow to the flank or the upper
abdomen or lower chest. One should be aware of preexisting renal anomalies which make the kidney more
vulnerable. Physical examination is the basis for the initial assesment. The following signs indicate possible
renal trauma:
- hematuria
- flank pain
- flank ecchymoses and abrasions
- fractured ribs
- abdominal distension
- abdominal mass and
- abdominal tenderness
Hematuria is the hallmark, but does not correlate with the degree of injury. Transection of the ureteropelvic
junction, renal pedicle injuries and renal artery thrombosis usually go without hematuria. Urine dipstick is a
reliable and rapid test, being false negative in 2,5-10% (9).
Imaging
Indications for radiographic evaluation are gross haematuria, microscopic haematuria and shock, and
presence of major associated injuries (10). It should be done when fractures of the lower ribs and upper
lumbar and lower thoracic vertebrae are detected. Patients with rapid deceleration injuries and penetrating
trauma to the torso need immediate imaging.
Ultrasonography
This popular imaging is quick, non-invasive, low-cost but the results are highly dependent on the examiner. It
cannot asses the depth and extent of the laceration and cannot provide information about the function. The
fluid collection and distribution is well detected and doppler assesment gives some information about the
tissue perfusion and renal vessels. It helps in the decision, which patients require more aggressive
radiological imaging.
Intravenous pyelography
It is still the best imaging study with a sensitivity of more than 92% and gives information about the presence
of both kidneys, clearly defines the renal parenchyma and outlines the collecting system. If there is no time to
perform the whole examination one-shot IVP is done in the operating suite.
Computed tomography (CT)
When the patient is stable or needs CT scanning for other reasons a contrast CT of the kidneys and
surrounding abdominal organs is the gold standard. It is more sensitive and specific than IVP. Spiral CT is
more rapid but des not provide enough information about the excretory phase of the kidneys. Lacerations
with extravasation are not shown (11).
Angiography
CT has largely replaced angiography as the method for staging renal injuries. It is useful when selective
embolization for intrarenal bleeding from branching vessels is planned. When CT is not available and the
kidneys on IVP are not seen, angiography is the test of choice.
Treatment
Dealing with renal trauma the urologist's expectations are: information about the presence of both kidneys,
some data about the function and the extent of the injury.
Today the major dilemma is whether to explore the damaged kidney or not. It is clear that the preservation of
the kidney and minimal morbidity is the goal which cannot be always achieved, especially if the approach is
aggressive.
29

Major renal trauma (grade II to IV) represents only 5,4% of all renal trauma cases (10) and 98% of renal
injuries can be managed conservatively. Grade V renal injury is an absolute indication for surgery and so is
hemodynamic instability due to renal bleeding of any grade (12).
Failure of conservative treatment is 5% (13) and it is mainly due to bleeding, infection, perinephric abscess,
sepsis, urinary fistula, urinary extravasation and urinoma. Many of these early complications can be
managed with radiologic or endoscopic interventions (e.g. selective arterial embolisation, drainage).
URETERAL TRAUMA
Because of its protected location, small size and mobility the ureter is less vulnerable to trauma representing
1% of all urogenital traumas. Most of the injuries (75%) are iatrogenic and of these, 73% are gynaecological
in origin (14). Injury to the ureter threatens the ipsilateral kidney function.
The most diagnostic investigation is IVP with the detection of extravasation of radiological contrast media or
additionally, when time permits retrograde ureteropyelogram, where the lesion is promptly delineated. CT
scanning is time consuming as it takes at least 20 minutes for the contrast to extravasate.
In open surgery at least one third of the injuries are recognized immediately (15) and repaired. For small
lesions, a conservative approach with retrograde or antegrade stent placement is feasible.
BLADDER TRAUMA
Bladder trauma may be blunt, penetrating or iatrogenic. Bladder injury represents 2% of all abdominal
injuries that require surgery (16). Off all bladder ruptures, blunt trauma is the cause in 67-86%, most common
from motor vehicle accidents (17,18). Blunt bladder trauma is classified as extraperitoneal and
intraperitoneal..
70-97% of bladder injuries from blunt trauma come with pelvic fractures (19). Of them more than half are in
the pubic ramus (20). In the group of those with pelvic fracture 30% will have bladder rupture and only 5-10%
will have major injury (21). 25% of intraperitoneal bladder ruptures are without pelvic fracture (18). Combined
extra and intraperitoneal ruptures come in 2-20% (22) and with rupture of the prostatomembranous urethra in
10-29%.
The degree of wall injury and location are the basis for the classification by Sandler and associates (Table
2) (18).
Table 4: Classification of bladder injury
Type
Description
1 Bladder contusion
2 Intraperitoneal rupture
3 Interstitial bladder injury
4 Extraperitoneal rupture:
A. Simple
B. Complex
5 Combined injury
Two main clinical signs with diagnosis are gross haematuria (82%) and abdominal tenderness (62%) (23).
Inabilitiy to void, abdominal distension and bruises over supra and pubic area could be found. Rarely do we
see extravasation of urine which can be detected as swelling in the perineum, scrotal area or thighs.
Imaging
It should be stressed that retrograde cystography with 350 ml of contrast material gives an 85-100% positive
result (23). It should be followed by a drainage film where 13% of bladder ruptures are detected (18). CT
cystography may replace cystography when evaluating abdominal and pelvic trauma. The sensitivity is 95%
and specificity 100% (24).
30

Treatment
Blunt extraperitoneal rupture can be managed by catheter drainage only for 10 days to three weeks (25). If
bone fragments and entrapment are present or the bladder neck is injured, surgical intervention is mandatory
(22). Intraperitoneal rupture from blunt force has to be managed surgically. Because of the high degree of
force there may be associated injuries with 20-40% mortality rate. Peritonitis due to urine leakage heavily
worsens the prognosis. Penetrating trauma to the bladder should be explored and repaired promptly.
The follow up cystogram is obtained 7 to 10 day after surgical repair. All extraperitoneal ruptures if correctly
diagnosed should be healed by 6 weeks (most by 10 days, almost all by 21 days), proven by a cystogram.
URETHRAL TRAUMA
The male urethra is divided by the urogenital diaphragm into anterior (bulbar, penile in men) and posterior
(prostatic, bulbar in men). Women have only a posterior urethra.
The posterior urethra is injured with pelvic fracture. Road traffic accidents (70%), falls from height (25%) and
crushes are the cause (26). Blunt trauma is responsible in more than 90% of cases. The female urethra is
rarely injured by contusion or laceration by bone fragments.
Crush or deceleration impact injury produces shearing forces to fracture pelvic bones. The same forces
stretch or tear the prostato-membranous junction. The prostate can be detached from its insertions to the
posterior face of the pubic bone and displaced.
In a stable pelvic fracture, the anterior entire or part of the pubic bone is broken. In almost all cases of four
pelvic rami fracture (straddle fracture) with posterior urethral rupture the distal sphincter mechanism is
destroyed, representing 41% of all prostatomembranous urethral injuries. In unstable pelvic fracture the
distorsion of the bony pelvis is responsible for the urethral tear.
Urethral injuries are never life-threatening. Associated injuries are much more important in initial
management.
Colapinto and McCallum classified posterior urethral injuries on the basis of radiographic findings (Table 3)
(27).
Table 3: Classification of posterior injuries according to Collapinto and McCallum
Type Description Radiographic appearance
1 Urethral contusion or stretch injury Passage of contrast into the bladder, without
extravasation and elongation of posterior urethra
2 Partial or complete rupture above the
urogenital genital diaphragm (supradiaphragmatic
rupture)
3 Complete disruption of the membranous
urethra and urogenital diaphragm (suband
supra- diaphragmatic rupture)
Contrast may reach the bladder, but
extravasation is present into the pelvis
Contrast does not reach the bladder and
extravasation is seen into the perineum
Further classifications were developed including anatomy and treatment strategies (Table 4) (28).
Table 4: Classification of urethral injuries according to Goldman et al.
Type
I
II
III
IV
IVa
V
Description
Posterior urethra stretched but intact
Tear of the prostatomembranous urethra above the urogenital diaphragm
Partial or complete tear of both anterior and posterior urethra, with disruption of the urogenital
diaphragm
Bladder injury extending into the urethra
Injury of the bladder base with periurethral extravasation simulating posterior urethral injury
Partial or complete pure anterior urethral injury
31

Finally the newest classification by EAU Urological guidelines proposes a classification which combines
previous classifications and leads to proper clinical management (Table 5).
Table 5: Classification of blunt anterior and posterior urethra
Classification
I
II
III
IV
V
VI
Description
Stretch injury. Elongation of the urethra without extravasation on rethrography
Contusion. Blood at the urethral meatus; no extravasation on urethrography
Partial disruption of anterior or posterior urethra. Extravasation of contrast at injury site
with contrast visualized in the proximal urethra or bladder
Complete disruption of anterior urethra. Extravasation of contrast at injury site without
visualization of proximal urethra or bladder
Complete disruption of posterior urethra. Extravasation of contrast at injury site without
visualization of bladder
Complete or partial disruption of posterior urethra with associated tear of the bladder
neck or vagina
Type I requires no treatment. Types II and III can be managed conservatively with cystostomy or urethral
catheter. Types IV and V require open or endoscopic, primary or delayed treatment. Type VI requires open
repair.
Anterior urethral injuries result mostly from blunt trauma. With fall or blow the bulbar urethra is compressed
against the inferior surface of the symphysis pubis. Occasionally we see corpora cavernosa rupture with
urethral rupture, which occur during intercourse. Penetrating trauma is even less common. Constriction
bands for urinary continence and chronic urethral catheters of larger dimensions injure the urethra because
of ischaemia, as does cardiac bypass surgery.
Clinical assessment
Blood at the urethral meatus is highly suspicious of urethral injury. It is present in 37-93% of patients with
posterior urethral injury and in 75% with anterior (29). There should be no instrumentation in this case and
radiological imaging of the urethra is done. In the unstable patient a urethral catheter can be gently
attempted to pass but in any difficulty a suprapubic catheter should be placed. More than 80% of women with
pelvic fracture and urethral injury will have blood at the vaginal introitus (30). High riding prostate is an
unreliable sign as most of the injured are young with a small prostate. There is pelvic haematoma which des
not allow exact conclusion.
Imaging
Retrograde urethrography is the gold standard. A plain film should be first performed to se any bony
fragments or foreign bodies. It is easy to insert a 12 or 14 Fr Foley catheter in the fossa navicularis and
inflate the balloon with 1-2 ml of water to occlude the urethra. Usually, in heavily injured the oblique position
is not possible and the appearance of the urethra is not ideal. If the posterior urethra is injured a suprapubic
catheter is placed well above the pubic bone if it is broken. Double imaging (ante and retrograde
urethrogram) is possible. If displacement is present a delayed suprapubic endoscopy to evaluate the bladder
neck is possible and a radiological evaluation of the proximal urethra with the endoscope in it. CT and MRI
are not useful in assessment of urethral injuries (31) as well as endoscopy as the initial diagnostic procedure.
Treatment
Primary realignment of posterior urethral disruptions gives a lower stricture rate as suprapubic catheter
alone. The urethral continuity is achieved. The prostate and urethra are aligned. The restricture rate is 62%.
Open urethroplasty is not indicated because of bad visibility and more complications (incontinence, erectile
dysfunction, stricture).
Delayed primary urethroplasty is performed when a usually polytraumatized patient is stable, within 10 to 14
days. The main goal is to correct severe distraction injuries, not to prevent stricture.
Delayed urethroplasty
32

In all of the delayed procedures, repeated imaging is desired as the pathoanatomic situation changes, the
patient is more cooperative and stable thus more information is provided.
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1. Meng MV, Brandes SB, McAninch JW. Renal trauma: indications and techniques for surgical exploration. World J Urol 1999;17(2):71-
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2. Danuser H, Wille S, Zoscher G, Studer U. How to treat blunt kidney ruptures: primary open surgery or conservative treatment with
deferred surgery when necessary? Eur Urol 2001;39(1):9-14.
3. Krieger JN, Algood CB, Mason JT, Copass MK, Ansell JS. Urological trauma in the Pacific Northwest: etiology, distribution,
management and outcome. J Urol 1984;132(1):70-73.
4. Sagalowsky AI, McConnell JD, Peters PC. Renal trauma requiring surgery: an analysis of 185 cases. J Trauma 1983;23(2):128-131
5. Bruce LM, Croce MA, Santaniello JM, Miller PR, Lyden SP, Fabian TC. Blunt renal artery injury: incidence, diagnosis, and
management. Am Surg 2001;67(6):550-554
6. Sullivan MJ, Stables DP. Renal artery occlusion from trauma. JAMA 1972;221(11):1282.
7. Moore EE, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM, Gennarelli TA, Malangoni MA,
Ramenofsky ML, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma 1989;29(12):1664-1666.
8. Santucci RA, McAninch JW, Safir M, Mario LA, Service S, Segal MR. Validation of the American Association for the Surgery of
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10. Miller KS, McAninch JW. Radiographic assessment of renal trauma: our 15-year experience. J Urol 1995;154(2 Pt 1):352-355.
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Urol 1998;160(6 Pt 1):1979-1981.
12. Armenakas NA, Duckett CP, McAninch JW. Indications for nonoperative management of renal stab wounds. J Urol 1999;161 (3):768-
771.
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1991;146(2):274-276
14. Dobrowolski Z, Kusionowicz J, Drewniak T, Habrat W, Lipczynski W, Jakubik P and Weglarz W.Renal and ureteric trauma: diagnosis
and management in Poland. BJU Int 2002; 89(7): 748-751.
15. Grainger DA, Soderstrom RM, Schiff SF, et al: Ureteral injuries at laparoscopy: Insights into diagnosis, management, and prevention.
Obstet Gynecol 1990;75:839–843.
16. Carlin BI, Resnick MI.Indications and techniques for urologic evaluation of the trauma patient with suspected urologic injury. Semin
Urol 1995;13(1):9-24.
17. McConnell JD, Wilkerson MD, Peters PC.Rupture of the bladder. Urol Clin North Am 1982;9 (2):293-296.
18. Sandler CM, Goldman SM, Kawashima A.Lower urinary tract trauma. World J Urol 1998; 16 (1):69-75.
19. Flancbaum L, Morgan AS, Fleisher M, Cox EF.Blunt bladder trauma: manifestation of severe injury. Urology 1988;31 (3):220-222.
20. Cass AS.Diagnostic studies in bladder rupture. Indications and techniques. Urol Clin North Am 1989;16 (2):267-273.
21. Coppola PT, Coppola M. Emergency department evaluation and treatment of pelvic fractures. Emerg Med Clin North Am
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22. Dreitlein DA, Suner S, Basler J. Genitourinary trauma. Emerg Med Clin North Am 2001;19(3):569-590.
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1992;148(4):1162-1165.
33

UPPER URINARY TRACT TRAUMA
Anders Magnusson
Department of Radiology, Uppsala University Hospital, Sweden
RENAL TRAUMA
Mechanism of renal injury
Blunt abdominal trauma, frequently caused by car accidents, falls, contact sports and fights, is responsible
for more than 80% of all renal injuries. Other traumatic causes are penetrating violence (stab and gunshot
injuries) and iatrogenic injuries (shockwave lithotripsy, percutaneous biopsy and percutaneous
nephrostomy).
Predisposing factors
Preexisting conditions such as renal tumor and cyst, horseshoe kidney and hydronephrosis makes the
kidney more vulnerable. In children the kidneys are relatively larger and unprotected which makes them more
vulnerable.
Types of injury and classification
The type of injury varies with the severity of the trauma.
a) Renal contusion (intrarenal edema)
b) Hematoma (intrarenal, subcapsular or perirenal)
c) Laceration (subcapsular parenchymal tear)
d) Rupture (parenchymal tear with capsular injury)
e) Pedicle injuries
Renal injuries can be graded using a number of different classification systems which are used to guide
therapy. However urologists are turning more and more conservative in treating renal trauma and most
classification systems are not up to date.
Management of Renal Trauma
Most renal injuries are treated conservatively. If surgery is necessary delayed exploration is recommended
(>24 h). The goal is to drain the kidney and to remove nonviable tissue, not to reconstruct the kidney.
However, there is one exception from delayed intervention. Pedicle injuries with renal infarction require
immediate intervention as renal function is irreversibly lost in more than 90% of cases after 2 hours of
ischemia.
Radiological Workup and Findings
Suspected renal injury should be investigated as soon as possible. The following questions should be
answered:
• Are both kidneys present and are they functioning?
• Are there nonviable fragments?
• Is there a urinary extravasation?
• Is the urinary flow unobstructed?
These questions are best answered by CT. Contrast material should always be injected and imaging should
be performed during cortico-medullary as well as delayed excretory phase.
Contusion and Hematoma. A heterogeneous reduction in parenchymal enhancement reflects a renal
contusion (Fig. 1). Fresh parenchymal hemorrhage appears on noncontrast scans as a hyperattenuating
area.
Laceration. A laceration or fracture through renal parenchyma is often between major vascular branches.
Lacerations and ruptures are accompanied by subcapsular (Fig. 2) or perirenal hematomas (Fig. 3) of
variable size.
34

Shattered kidney. The most severe form of renal laceration is the shattered kidney. The kidney is fractured
into three or more separate fragments. It is important to identify devascularised fragments (Fig 4). The force
to the retroperitoneum that is necessary to shatter a kidney usually results in injuries to other organs in
addition.
Pedicle injury. Renal artery injury is due to a sudden stretch. Blood flow through the artery is blocked by an
intimal flap and thrombosis which results in segmental or global infarction. In complete renal infarction a
nonenhancing kidney is discovered on CT. Cortical rim sign represents a 2-3 mm thick dense outer
nephrogram and is pathognomonic for infarction. Retrograde filling of the renal vein is often detected in total
arterial occlusion.
Contrast extravasation. Contrast leakage from a ruptured collecting system often signifies major disruption of
renal parenchyma. Leakage is often found only on late excretory images (> 10 min.). A large collection of
contrast material located medially to the kidney is suggestive of pelvocalyceal or ureteral tear.
A new classification of renal injuries
This is a proposal of a new, simple classification of renal trauma:
I. Catastrophic injury
- Devascularised kidney
Treatment: Immediate surgery
II. Injury which requires surgery
- Large nonviable fragments
- Major urinary extravasation and obstructed flow
Treatment: Delayed surgery >24 h.
III. Injuries treated conservatively
- All other injuries
Treatment: Expectance
Fig. 1
Renal contusion. The contused part of the kidney
(arrowheads) shows hypofunction.
Fig. 2
Subcapsular hematoma with a typical compression of
the right kidney (arrows).
35

Fig. 3
Perirenal hematoma surrounding the right kidney
Fig. 4
Shattered kidney with non-enhancing devascularised
fragments (arrows)
TRAUMA TO THE URETHRA AND SCROTUM
Stanford M. Goldman, M.D.
The University of Texas Health Science Center at Houston
I. URETHRA
In order to evaluate urethral injury, one must know the urethral anatomy and the mechanisms of injury. The
significant clinical findings will be reviewed, followed by the various classifications (including the one we use)
that are used. Finally, the various methods of imaging of the urethra will be described as well as current
controversies in regards to treatment.
ANATOMICAL CORRELATIONS
The urethra is divided into two parts and each of these subdivided into two parts. The posterior urethra is
made up of the longer prostatic segment and the extremely short membranous urethra. The extrinsic
posterior compression by the verumontanum makes possible the recognition of the posterior urethra.
Immediately below this is the membranous urethra, which is surrounded by the external sphincter, the key to
male continence. This sphincter is part of the urogenital diaphragm (UGD) which acts as the main support of
the internal viscera in the upright position. The anterior urethra is divided by the bulbous and penile urethra.
The bulbous urethra consists of the 4-5 cm portion of the urethra below the symphysis pubis. Its posterior
aspect is cone shaped as it joins the membranous urethra. The remaining penile urethra ends as an out
pouching called the fossa navicularis. Surrounding the urethra is the facially encased corpus spongiosum.
On both sides superiorly is the corpora cavernosum.
MECHANISMS OF INJURY
An anterior urethral injury is usually secondary to a straddle injury (e.g. a motorcycle hitting a wall). Posterior
urethral injuries are usually due to crush injuries (e.g. an automobile accident invariably associated with a
pelvic fracture). Iatrogenic injuries (e.g. secondary to gynecological, prostatic or bladder surgery) are also
seen. Penetrating objects (e.g. knives, bullets, etc.) can also injure the penile urethra. Injuries secondary to
foreign body insertion may also occur.
36

SYMPTOMS AND PHYSICAL FINDINGS
Ten percent (10%) of patients with pelvic fractures may have accompanying urethral injuries. Many believe
that significant urethral injury does not occur without gross hematuria. Very rarely, microscopic hematuria
may be associated with a severe injury. With significant anterior urethral injury, one notes an enlarged,
discolored penis, scrotum and perineum. This swelling and discoloration may extend into the thigh. Blood at
the urethral meatus may be noted. The so-called “floating bladder and prostate” require immediate surgery.
CLASSIFICATION
The old classification divided urethral trauma into posterior and anterior injuries. Anterior injuries occurred
below the UGD and were secondary to a straddle injury. Posterior injuries resulted from blunt trauma with a
complete transaction of the urethra above the UGD. In 1977, Colapinto & McCallum in a seminal paper
suggested a new classification of blunt urethral injuries involving the “posterior” urethra. We believe this
classification confusing because it is not a pure anatomical classification, but is based on the mechanism of
injury and because many books have misunderstood these authors as sub-classifying purely posterior
urethral injuries. Our classification of urethral injuries follows and is compared to the other two widely used
classifications.
Type I - Posterior urethra intact but stretched (Colapinto and McCallum Type I)
Type II - Pure posterior injuries with tear of membranous Urethra above the urogenital
diaphragm – partial or Complete (Colapinto and McCallum Type II)
Type III - Combined anterior/posterior urethral injury with disruption of the urogenital diaphragm
– partial or complete (Colapinto and McCallum Type III injury)
Type IV - Bladder neck injury with extension into the urethra
Type IVA - Bladder neck injury
Type V - Pure anterior urethral injury – partial or complete
IMAGING TECHNIQUES
1). Retrograde urethrogram
This represents the main method of evaluating urethral injury. The Best technique is to place the Foley
catheter balloon in the fossa navicularis and to perform the study under fluoroscopy. In the emergency room,
the study can be performed blindly using a 50 cc beveled syringe or the Brodney clamp. The contrast should
be diluted to 10-15% to prevent the development of a urethritis and to prevent obscuring pathology by overly
dense contrast. In all suspected lower urinary tract trauma, the urethra should be evaluated before a
catheter is placed in the bladder to prevent the conversion of a partial tear to a complete one. If a drainage
catheter has already been placed into the bladder, the urethra can be studied by placing a small catheter
next to the bladder catheter and injecting contrast.
In complete anterior urethral tears, contrast fails to enter the bladder, but the contrast dissects into the
scrotum, penis and along Colles’ fascia toward the umbilicus and even into the thigh. In type I injuries of the
posterior urethra, there is only a stretching and narrowing of the urethra. This injury may require no
treatment or only short-term catheter drainage. In type II injuries, the extravasation occurs just above the
UGD. The bladder is elevated and pear-shaped and may mimic an extraperitoneal bladder injury. In type II
injuries, contrast extravasates high below the bladder. These are indistinguishable radiologically and require
follow-up or surgery. In type V tears, the contrast is seen below the symphysis pubis. In incomplete or
partial tears, some contrast enters the bladder.
2). Computed tomography
CT is not routinely needed in evaluating urethral injuries. However, in select cases, residents and
inexperienced faculty have used it to confirm the location of extravasated contrast from the urethrogram.
Recently, Radiographics article with Ali, et al has suggested that CT being performed in patients with multiple
trauma is valuable in predicting the presence and type of injury. This needs to be confirmed by others.
37

3). Magnetic resonance imaging
This technique is not used acutely because of expense and lack of ready availability on a 24-hour basis.
However, Dixon et al, has shown it to be excellent in the pre-operative evaluation of the injured urethral
because of its multiplanar capabilities and its ability to evaluate the surrounding soft tissues.
TREATMENT
In the past, immediate surgical repair was performed. Some trauma surgeons still operate on these patients
acutely, claiming a lower incidence of complications. This approach can only be used by experienced
trauma urologists, as will be discussed. Most urologists treat conservatively, except in the case of the
floating prostate or in select type IV injuries to prevent urinary incontinence. If a catheter can be placed
gingerly through the urethra in incomplete tears into the bladder, then the catheter acts as a urethral stent.
Unfortunately, this catheterization is often unsuccessful, but some feel it is worthwhile trying. If not, a
suprapubic tube is placed and a stricture is allowed to form. Surgery is then performed from above or below
as appropriate. Impotence is less often a problem with the conservative approach over time.
CORPORAL INJURIES
Where injuries of the corpus cavernosum or corpus spongiosum is suspected, an ultrasound or MRI should
be performed. Ultrasound is usually readily available, but often difficult to interpret because of the associated
hematomas that are so often present. MRI gives more anatomical detail in multiple planes, but is not always
available. Corpus cavernosonography may also be used. The surgeon is interested in the status of Buck’s
fascia since severe tears of this fascia require repair.
II. SCROTAL INJURIES
The scrotum can be injured by either blunt or penetrating injuries. In these injuries, the urologist is most
interested to know if the fascia surrounding the testes is intact in order to determine whether surgical
intervention is indicated. Ultrasound is the technique most often used because of its ready availability.
Unfortunately, the omnipresent edema and hemorrhage often make it difficult to answer this question. MRI, if
available, may be more diagnostic in these situations. Besides tears of the fascia, intervention for significant
hematomas are advocated in order to prevent loss of testicular function
References
1. Colapinto V, McCallum RM. Injury to the male urethra in the fractured pelvis: A new classification. J Urol 1977; 118-575-585.
2. Dixon CM, Hricak H, McAninch JW. Magnetic Resonance Imaging of Traumatic Posterior Urethral Defects and Pelvic Crush Injuries.
J Urol 1992;148:1162-1165.
3. Kawashima A., Sandler CM, Corriere JN, Goldman SM. Type IV urethral injuries: retrograde urethrographic findings in six cases.
Radiology 1998; 209(P):335.
4. Kawashima A, Sandler SC, Corriere JN, Rogers BM, Goldman SM.
Ureteropelvic junction injuries secondary to blunt abdominal trauma. Radiology 1997:205:4787-4792.
5. Sandler CM. Urinary Tract Trauma in Textbook of Uroradiology, 3 rd ed. Edited by Dunnick NR, Sandler CM, Newhouse JH, Amis ES
Jr. Philadelphia: Lippincott Williams & Wilkins, pp. 473-483, 2001
URETERAL AND BLADDER INJURIES
Carl M. Sandler, M.D.
University of Texas MD Anderson Cancer Center Houston, Texas
Email: carl.sandler@di.mdacc.tmc.edu
URETERAL INJURIES
The ureter may be injured by blunt, penetrating or iatrogenic trauma.
Almost all blunt ureteral injuries occur at the ureteral pelvic junction (UPJ) as a result of a deceleration injury.
With rapid deceleration, the ureter may be avulsed or lacerated from its connection to the renal pelvis. The
injury results in extravasation of urine (or contrast material) from the renal pelvis at the UPJ. On both
38

urography and by CT, medial perinephric contrast material extravasation associated with a circumrenal
urinoma is the characteristic finding. With complete avulsion, no filling of the ureter distal to the site of injury
is present; with laceration, some filling distally is usually present. The differentiation is important as complete
avulsion requires surgical repair whereas laceration may be treated conservatively or with a ureteral stent.
Penetrating ureteral injury almost always occur with a wound to the back when caused by stabbings or
anywhere in the path of the missle when due to gunshot wounds. The injury generally results in contrast
material extravasation on imaging. On occasion, contrast extravasation will be present when the injury has
been close to the ureter but not directly in its path as a result of blast effect and resultant ureteral necrosis.
The majority of ureteral injuries are iatrogenic. The ureter may be tied or injured with any type of pelvic
surgery but is particularly common with gynecologic procedures such as hysterectomy and laparoscopy.
The injury may not be apparent for several days; in such cases fever of unknown cause may be the initial
presenting symptom. Ureteral injury is also common in a wide variety of urologic procedures including
ureteroscopy and stone basketing.
BLADDER INJURIES
Injury of the bladder may occur as a result of blunt, penetrating or iatrogenic trauma. The susceptibility of the
bladder to injury varies with its degree of filling; a collapsed or nearly empty bladder is much less vulnerable
to injury than is a distended organ.
Radiologic Examination: The static or CT cystogram is the examination of choice for the diagnosis of a
bladder injury. At least 300 ml of contrast should be used and with a conventional cystogram, a postdrainage
radiograph following as complete emptying of the bladder as possible must be included. Studies have shown
that the diagnosis of bladder injury may be established on this radiograph only in approximately 10% of the
cases.
The accuracy of cystography for the diagnosis of bladder injuries varies between 85-100% in the reported
series. All authors stress, however, that careful attention to proper technique in the performance of
cystography is necessary to achieve a high degree of accuracy. Falsely negative cystograms have been
more commonly reported in patients suffering injury to the bladder secondary to small caliber bullets. In such
cases, it is assumed that the bladder rent seals with either mesentery or blood clot and result in the falsely
negative examination.
Because computed tomography has gained increased acceptance for the evaluation of patients suffering
blunt abdominal and pelvic trauma, there has been recent interest in the value of this modality for the initial
evaluation of bladder injuries. Me and coworkers demonstrated that CT cystography performed utilizing
excreted contrast material after intravenous injection was unreliable for the detection of acute bladder
injuries, when compared to conventional cystography. Their findings were not surprising since it is well
known that the cystographic phase of an excretory urogram is also unreliable for the detection of major
bladder injuries. Subsequently, studies in which CT cystography was performed with retrograde filling of the
bladder utilizing diluted contrast material report an accuracy comparable to that obtained with conventional
cystography.
Bladder Injury in Blunt Pelvic Trauma: Major bladder injury occurs in approximately 10% of patients suffering
pelvic fracture. Such injuries are classified radiologically as:
Type I
Type II
Type III
Type IV
Type V
Bladder Contusion
Intraperitoneal Rupture
Interstitial Bladder Injury
Extraperitoneal Rupture
a. Simple
b. Complex
Combined Bladder Injury
39

Bladder contusion (Type I) represents an incomplete tear of the bladder mucosa following blunt injury. The
results of cystography are normal. The diagnosis of bladder contusion is usually established by exclusion in
patients with hematuria following blunt pelvic trauma for which no other cause is found. While bladder
contusion is generally regarded as the most common form of bladder injury following blunt trauma, it is not
considered to be a major injury. Intraperitoneal rupture (Type II) occurs when there is a sudden rise in
intravesicle pressure as a result of a blow to the lower abdomen in a patient with a distended bladder. The
increased intravesicle pressure results in rupture of the weakest portion of the bladder, the dome, where the
bladder is in contact with the peritoneal surface. Intraperitoneal rupture accounts for approximately one-third
of major bladder injuries. Approximately 25% of such injuries occur in patients without pelvic fracture. On
cystography, contrast material extravasation into the paracolic gutters and outlining loops of small bowel will
be present. Interstitial bladder injury (Type III) represents an incomplete perforation of the bladder wall
without frank rupture. On cystography a mural defect in the bladder wall will be found, but there is no
contrast material extravasation. The classically described mechanism for extraperitoneal bladder rupture
(Type IV) is laceration of the bladder by a bone spicule in association with an anterior pelvic arch fracture.
Recent data, however, has shown that cystograms in such patients often demonstrate that the site of
contrast material extravasation is often far removed from the site of fracture and thus the validity of this
mechanism has been questioned. Extraperitoneal rupture represents approximately 60% of major bladder
injuries. With simple extraperitoneal rupture, contrast extravasation is limited to the pelvic extraperitoneal
space. With complex extraperitoneal rupture, contrast material extravasation may extend into the anterior
abdominal wall, the penis, the scrotum and the perineum. The presence of a complex extraperitoneal injury
implies that the fascial boundaries of the pelvis have been disrupted by the injury. Such findings should not
be mistaken as evidence of a coexisting urethral injury. Combined bladder injury (Type V) results when both
intraperitoneal and extraperitoneal bladder injury is present. This injury represents approximately 5% of
major bladder injuries.
External Penetrating Bladder Injury: Penetrating injury of the bladder occurs as a result of bullet or knife
wounds of the pelvis or perineum or as the result of impalement of the bladder by a variety of objects.
Penetrating injuries are classified as intraperitoneal rupture, extraperitoneal rupture or combined bladder
injury.
References
1. Kawashima AK, Sandler CM, Corriere JN Jr, Rodgers B, Goldman SM: Ureteropelvic junction injuries secondary to blunt abdominal
trauma. Radiology 205:487-492, 1997
2. Vaccaro JP, Brody JM: CT cystography in the evaluation of major bladder trauma. RadioGraphics 20(5):1378-1381, 2000
3. Sandler CM, Hall JT, Rodriguez MB, Corriere JN Jr: Bladder injury in blunt pelvic trauma. Radiology 158(3):633-638, 1986
4. Peng MY, Parisky TY, Cornwell EE III, Radin R, Bragin S: CT cystography versus conventional cystography in evaluation of bladder
injury. AJR 173(5):1269-1272, 1999
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,
2000
6. Corriere JN Jr, Sandler CM: Mechanisms of injury, patterns of extravasation and management of extraperitoneal bladder rupture due
to blunt trauma. J Urol 139(1):43-44, 1988
7. Deck AJ, Shaves S, Talner L, Porter JR: Current experience with computed tomographic cystography and blunt trauma. World J Surg
25(12):1592-1596, 2001
8. Deck AJ, Shaves S, Talner L, Porter JR: Computerized tomography cystography for the diagnosis of traumatic bladder rupture. J Urol
164(1):43-46, 2000
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,
1989
10. Morgan DE, Nallamala LK, Kenney PJ, Mayo MS, Rue LW III: CT cystography: radiographic and clinical predictors of bladder
rupture. AJR 174(1):89-95, 2000
11. Morey AF, Iverson AJ, Swan A, Harmon WJ, Spore SS, Bhayani S, Brandes SB: Bladder rupture after blunt trauma: guidelines for
diagnosis imaging. J Trauma 51(4):683-686, 2001
12. Carroll PR, McAninch JW: Major bladder trauma: mechanisms of injury and a unified method of diagnosis and repair. J Urol
132(2):254-257, 1983
13. Corriere JN Jr, Sandler CM: Bladder rupture from external trauma: Diagnosis and management. World J Urol 17(2):84-89, 1999
40

URINARY OBSTRUCTION: A UROLOGIST′S PERSPECTIVE
Imaging and intervention of obstruction
Andrej Kmetec
Department of Urology, University Medical Centre Ljubljana, Slovenia
Urinary system obstruction is a common cause of acute and chronic renal failure. Evaluation and
management of obstruction is of key importance to preserve renal function. Symptoms and signs of
obstruction can be in the acute phase clearly expressed, while in the chronic phase they are mild or with long
announcing history. The urinary tract is a connected system originating from the renal collecting tubules to
the ureter and bladder and ending at the urethral orrifice. Any obstacle in the lower urinary parts causes
higher pressure of urine above the obstruction and is later transmitted to the upper urinary tract, directly to
the nephron tubules. Obstruction can be complete or partial, on one side or both sides, acute or chronic. In a
human lifetime, we can observe two or even three peaks when obstruction is more often recognised. The first
peak is observed in childhood, resulting from hereditary disorders involved in the urinary tract development.
The second one, a lower peak, is expressed in mid lifetime between 30 and 40 years of age, resulting in
obstruction from urinary stones or extrinsic processes such as compression from lymph nodes,
retroperitoneal fibrosis or trauma accidents. The third peak of obstruction comes after 60 years of age mostly
from obstruction in the lower urinary tract from benign prostate enlargement, cancer or urethral stenosis
(1,2,3).
Usually we use two conceptions: obstructive uropathy, which means disturbance in urine flow with renal
function preserved, but lowered. If blockade is eliminated in time a complete recovery of renal function is
expected. In such case, obstruction is acute, partial and one sided. The second conception is obstructive
nephropathy in which blockade of the urinary system causes deterioration of renal function in such a degree
that it cannot be reversed even when obstruction is eliminated. If the obstruction lasts 24 hours, renal
function recovers in 7 to 10 days after it has been eliminated. If obstruction lasts 2 to 3 weeks, renal tubular
function is permanently damaged and transition occurs from obstructive uropathy into obstructive
nephropathy. In 4 to 8 weeks of obstruction, renal function ceases and we speak of an afunctional kidney.
This happens when silent, gradually arising chronic obstruction in lower parts of the urinary system appear
with chronic urine retention and high pressure in the bladder, which is transmitted to the upper urinary
system or when retroperitoneal fibrosis compresses both ureters. Urine volume production can be normal,
but the urine is not concentrated, the kidney is enabled to eliminate waste body products. Urine production
depends on three factors: the pressure gradient from the glomerulus to the Bowman′s capsule, the peristalsis
of the renal pelvis or ureters, and the effects of hydrostatic pressure (4.5).
Causes of urinary obstruction are divided as follows:
Infravesical: urethral strictures, posterior urethral valves, benign prostate enlargement, abscess
in prostate, prostate cancer
Supravesical: 1 Exstrinsic obstruction
a/ vessels anomalies (retrocaval ureter, aortal aneurysm)
b/ gynaecological diseases
c/ gastrointestinal diseases (Chron′s disease, cancer, pancreatitis)
d/ retroperitoneal lesions (fibrosis, tumours, lymph nodes)
2 Intraluminal obstructions
Pelviureteric stenosis, urolithiasis, blood clots, necrotic papilas
Urotelial cancer, ureteral strictures
3 Iatrogenic lesions- during gynaecological or bowel operations
4 Obstruction in transplanted kidney
Blood clots, stones, necrosis or stricture in transplanted ureter
Stenosis or oedema in ureteral orifice, lymphocoele
Pathoanatomic changes
Above the place of obstruction there is urine stasis with higher pressure and dilatation of the collecting
system. Higher pressure is transmitted to the kidney, causing interstitial nephritic fibrosis spread particularly
round the Bowman′s capsule. This lesion can be observed even prior to 28 days of obstruction. Renal tissue
41

gradually becomes thin – atrophic. Fibroblast spreading and collagen deposition in the renal tubule can be
recognised after 2 weeks when the tubular basement membrane thickens (5, 7).
Physiological changes
Physiological changes can be seen in three phases as changes of the ureteric pressure, renal blood flow,
glomerular filtration rate and tubular function during the first 18 hours after the obstruction appears. These
changes are in the first phase oriented to increase the production of urine, while increasing the pressure
intends to overcome obstruction. In the next phases, changes are intended to minimise damage to the kidney
caused by obstruction. Variables measured during obstruction are represented in table 1 (6, 2, 4, 7).
Table 1 Kidney response to acute obstruction.
Phase 1
1(0-90 min)
Phase2
(90 min-5h)
Phase 3
(5-18h)
Increase to 50-70 mmHg Initial sharp fall
plateau
Gradual decrease with
reduced renal blood flow
After 4 hours reduced to
52%
Reduced to 23% at 12 h
and 2% at 48h
Initial increase due to
preglomerular vasodilatation
Reduced with post glomerular
rise in resistance
Progressive reduction with
preglomerular vasoconstriction
Leahy AL e tal. J Urol 1989.
Renal tubular function: the renal concentration ability is affected early with the production of a large volume
of hypotonic urine. This is a response when the kidney tends to overcome obstruction. Namely, in obstruction
the prostaglandine production increases and blocks the antidiuretic hormone efect. Beside this reaction there
is insufficient acidification and renal tubular acidosis appears. Potassium reabsorbtion is lowered first, later
after 24 hours it increases and hyperkalemia occurs. Renal tubular permeability is increased (6) (Table 2).
Table 2 Tubular function
Acute obstruction
Chronic obstruction
Reabsorbtion Na + Raised Lowered
Reabsorbtion K + Lowered Raised
Concentrating ability Reduced or N Reduced
Acidification N or slightly reduced Reduced
Imaging and diagnosis
Physical signs suggesting the use of imaging studies to confirm obstruction: renal colics with or without
haematuria, miction disorders, low urine volume output or even absence of urine, incontinence, frequent
infections, hypertension and renal failure (2).
Dilatation of the urinary collecting system is the main sign of obstruction. The goal of the imaging study is to
determine the site of obstruction and to distinguish obstructive dilatation from nonobstructive-functional
dilatation. The latter is seen in an ectopic kidney, a kidney after certain surgical operations, an extrarenal
pyelon, congenital megacalyces, calyceal diverticula, vesicoureteral reflux and some other causes. We must
be aware, that obstruction in the first some hours can be without dilatation. The first examination is the plain
X ray picture which presents stones in the urinary tract and an ultrasound examination showing dilatation, but
the exact site of the obstruction lower to the pyeloureteric part cannot be identified. The ultrasound
examination is subjected to individual interpretation and in 20% there are false positive or negative results
(8). In the acute phase when there is no obvious dilatation, Doppler ultrasound and calculating resistent
indexes can differentiate between obstructive and nonobstructive dilatation. A resistive index 0,7 and over
confirms obstructive dilatation (8, 11). Some additional information in the detection of hydronephrosis gives a
radionucleotide scan, having 90% sensitivity, but the exact location of obstruction also cannot be defined. In
acute obstruction it shows renal function, which can be even worse then it exists on itself. Intravenous
pyelography is still the procedure of choice for defining the extent and anatomy of obstruction, which is still
quite useful in stone disease and helps to make an appropriate decision about therapy. It has disadvantages
like nephrotoxity and a long time of dye excretion in patients with renal failure. The same is with invasive-
42

etrograde pyelography which is useful in visualising tumours in the renal pelvis. In such cases, both imaging
techniques cannot replace CT or MR. Contrast X ray uretrography is still the best way to determine urethral
stricture or stricture at the bladder neck. Today, contrast CT or spiral CT is the best way to determine the
extent and location of obstruction (9, 2).
Management of urinary obstruction
Treatments of obstruction are divided into those for early relief of urine blockade with intention to prevent
damage and deterioration of renal function. After acute obstruction is solved and renal function normalises,
we have time enough for additional imaging and getting information for final decisions. Three main areas
have developed in urology: interventional urology, the development in the technology of protheses and
stents, endoscopy with a new technology in surgery.
Urethral obstruction due to stricture can be solved by thin catheter insertion, if it is not possible, suprapubic
cystostomy catheter drainage is the best solution. Urine retention due to prostate enlargement is solved
using urine catheters or suprapubic cystostomy drainage. The final solution is done by endoscopic resection
of the enlarged prostate. A prothesis disposed on the urethral stricture or on the bladder neck is not the best
solution, because it can slip out of position, causing incontinence or fibrous tissue can spread through the
prothesis. Removing the prothesis out of the urethra or bladder can sometimes be nearly impossible.
Ureteral stone obstruction causes stretching of the collecting system and produces colic pains. More than
90% of the stones less than 5-7mm in size pass spontaneously. If obstruction is severe JJ stent insertion
passes the stone and decompresses the kidney. The position of the stone determines the preferred method
of removal – ureterorenoscopy, percutaneous nephroscopy or shock wave lithotripsy. Long standing stone
obstruction is complicated by infection. In such cases percutaneous nephrostomy is safer than retrograde
catheterisation, which may introduce infection into the closed blockaded urinary system. Sometimes JJ
insertion is a good temporary solution in cases of enlarged lymph nodes or others extrinsic lesions
compressing the ureter. Gynaecological or bowel cancer compresses and invades the ureter in such way
that it is better to insert a percutaneous nephrostomy tube. Retroperitoneal fibrosis or aortal aneurysm cause
mild and proximal ureter obstruction, percutaneous nehrostomy is indicated instead of a JJ stent. Stents
block ureter peristaltic and make intraluminal ureter compression so it is advisable that patients have
nephrostomy for some months. When ureters are decompressed after appropriate therapy seen on contrast
X ray imaging through the nephrostomy tube stents can be inserted (2).
Used urine catheters, splints or nephrostomies are usually temporary interventions to avoid obstruction and
preserve renal function. Elective surgery or endoscopic procedures may then be performed after adequate
definition of the place and cause of obstruction. In some patients having bad prognosis as in advanced
cancer disease, nephrostomy or splints can be a definite solution to maintain at least adequate renal
function.
Every obstruction in the urinary system may cause infection and urosepsis. Obstruction treatment may
introduce infection into the closed urinary system. A urinary catheter can in three days cause bacterial
infection in the lower urinary tract. Ureteral catheters and splints can introduce infection into the upper urinary
tract. Splints may cause complications such as movement out of the bladder to the upper tract or they can
fall into the bladder, cause haematuria, or pain in the loins due to vesicoureteral reflux. Percutaneous
nephrostomy insertion may also introduce bacteria into the urinary tract, producing haematuria and later
calcium settings on the tube which makes tube occlusion. We suggest that preventive antibiotic therapy is
advisable in all cases when artificial materials stay in the urinary system for a longer period.
Transplanted kidney
Patients with a transplanted kidney have immunosuppressive therapy and are susceptible for infections. In
the transplanted kidney, ureter stenosis in the lower part of the ureter or stenosis at the new-formed orifice
causes dilatation of the urinary system. Retrograde insertion of a ureter catheter or JJ splint is almost always
impossible; also infection can be introduced into the kidney. Percutaneous nephrostomy insertion is
mandatory. Later we can perform contrast imaging through the tube or CT to visualise the extent and exact
place of stenosis. The cause of ureteral stenosis is insufficient blood supply or knicking of the ureter. The
interventional radiologist can dilate the stenosis and insert a splint through the nephrostomy, but this is not
the final solution. The splint may further compromise the ureter blood supply. To solve the problem, surgical
resection of the ureter, using bladder flap to elongate the gap between the bladder and the ureter and
neoimplantation is mandatory. Sometimes the patient’s own ureter is used instead of the transplanted one.
External compression and obstruction can cause lymphocoele. Simple tube insertion into the lymphocoele
43

cavity produces lymphatic drainage for a long period, loosing proteins with bacterial invasion into the cavity. It
is advisable to drain the lymphocoele into the abdominal cavity where the lymph spontaneously resorbs. In
the transplanted kidney, urinary stones or blood clots may produce obstruction. If dilatation stands for a
longer period percutaneous nephrostomy insertion is advisable to prevent kidney deterioration and to wait for
particles to eliminate spontaneously (12).
Conclusion
Recognition and detection of urinary obstruction using appropriate imaging methods enables to apply
suitable methods to free urine flow and prevent renal damage or infection. Insertion of splints,
nephrostomies, and catheters is a time limited procedure to alleviate the acute phase of obstruction and to
consider about further decisions. The final solution of obstruction is surgical or endoscopic, except in patients
having advanced disease with bad prognosis. Obstruction which lasts for a longer period produces infection
with renal function deterioration. Artificial materials introduced into the urinary system may cause chronic
infection which affects also the renal function. A combination of intraluminal stenting and urinary system
reconstruction will give the best results and minimise morbidity.
LITERATURE
1. Kmetec A, Oblak C. Najpogostejši vzroki zapore zgornjih sečil in naši diagnostični postopki.Zbornik podiplomskega tečaja kirurgije,
Ljubljana 1992; 164-169.
2. Janež J. Patofiziologija zapore sečil. Zbornik podiplomskega tečaja kirurgije, Ljubljana 1992; 153-163.
3. Catell R W. Renal function and obstructive nephropaty; in Webster G, Kirby R, King L, Goldwaser B: Reconstructive urology,Boston
Vol1, Blackwll Scientific Publications. 1993. 5-13.
4. Klahr S. Obstructive nephropathy. Kidney Int 1998; 54: 286-300.
5. Gulmi FA, Felsen D, Vaughan ED Jr: Pathophysiology of urinary tract obstruction; in Walsh PC, Retik AB, Vaughan ED Jr, Wein A:
Campbell′s Urology, ed 7. Philadelphia, Saunders, 1977, 342-385.
6. Sharma AK, Mauer SM, Kim Y, Micharl AF. Interstitial fibrosis in obstructive nephropathy. Kidney Int 1993; 44: 774-780.
7. Ryan CP, Maher KP.Murphy B,Hurley DG, Fitzpatrick MJ. Experimental partial ureteric obstruction: pathophysiological changes in
upper tract pressures and renal blood flow. J Urol 1987; 138: 674-8.
8. Kmetec A. Ultrazvok v klinični diagnostiki obstrukcije sečil. Thesis, Ljubljana 1999.
9. Steinhausen e tal. Glomerular blood flow. Kidney International 1990; 38:769-84.
10. Catalano C, Pavone P, Laghi A. MR pyelography and conventional MR imaging in urinary tract obstruction. Acta Radiol, 1999, 40:
1107-13.
11. Platt JF. Urinary obstruction. Radiol Clin N Amer 1996; 34: 1113-1129.
12. Kahan B, Ponticelli C. Principles and practise of renal transplantation. Martin Dunitz Ltd Blackwell Scientific publication, 2000.
IMAGING OF STONES: PLAIN FILM, IVU, AND ULTRASOUND
Gertraud Heinz-Peer, M.D.
Dept. of Radiology, Medical University of Vienna
Urolithiasis is a common problem in patients presenting to emergency departments. Radiologic imaging has
always had a primary role in the work-up of these patients. Traditionally, evaluation consisted of conventional
radiography (KUB) followed by intravenous urography (IVU). With the advent of ultrasonography (US) those
patients who could not safely undergo IVU could be evaluated for primary or secondary (ie, hydronephrosis)
signs of obstruction. In the past several years, the introduction of unenhanced spiral CT has dramatically
changed the role of the various imaging techniques in evaluation of urolithiasis. The number of pulications on
the issue of intravenous urography (IVU) versus computed tomography (CT) is abundant. During the last
years advocates of the CT make up the majority. In the recent literature some authors believe that it is time
for IVU to retire after 70 years of good performance. However, daily practice shows that urologists still like
those “old” techniques.
This lecture will review the pros and cons of KUB, IVU, and ultrasound. In addition, aspects of radiation
dosage, requirements for further imaging, impact on urological interventions and follow-up examinations as
well as aspects on diagnostic utility and the measured clinical outcome will be addressed.
44

Learning objectives:
1. Assess the advantages and limitations of KUB, IVU, and ultrasound
2. Work out remaining diagnostic fields for these techniques
3. Learn about relation between imaging and clinical management of urolithiasis
References
1. 8 Swick M. Demonstration of the kidneys, ureters, bladder and urethra by x-rays using intravenous administration of a new contrast
medium uroselectan. Klin Wschr 1929; 8:2085-2087.
2. 9 Dalla Palma L, Stacul F, Bazzocchi M et al. Ultrasonography and plain film versus intravenous urography in ureteric colic. Clin
Radiol 1993; 47:333-336.
3. 10 Sourtzis S, Thibeau, Damry N, Raslan A, Vandendris M, Bellemans M. Radiologic Investigation of Renal Colic: Unenhanced Helical
CT compared with Excretory Urography. AJR 1999; 172:1491-1494.
4. 11 Liu W, Esler SJ, Kenny BJ, Goh RH, Rainbow AJ, Stevenson GW. Low-Dose Nonenhanced Helical CT of Renal Colic: Assessment
of Ureteric Stone Detection and Measurement of Effective Dose Equivalent. Radiol 2000; 215:51-54.
5. 12 Miller OF, Rineer SK, Reichard SR, Buckley RG, Donovan MS, Graham IR, Goff WB, Kane CJ. Prospective comparison of
unenhanced spiral computed tomography and intravenous urogramin the evaluation of acute flank pain. Urol 1998; 52:982-987.
6. 13 Dalla Palma L. What is left of i.v. urography? Eur Radiol 2001; 11:931-939.
7. 17 Levine JA, Neitlich J, Verga M, et al. Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced
helical CT. Radiology. 1997; 204:27-
8. 18 Ripolles T, Agramunt M, Errando J, Martinez MJ, Coronel B, Morales M. Suspected ureteral colic: plain film and sonography vs
unenhanced helical CT. A prospective study in 66 patients. Eur Radiol 2004; 14:129-136.
9. 19 Catalano O, Nunziata A, Altei F, Siani A. Suspected ureteral colic: primary helical CT versus selective helical CT after unenhanced
radiography and sonography. AJR 2002; 178:379-387.
10. 21 Deyoe LA, Cronan JJ, Breslaw BH, Ridlen MS. New techniques of ultrasound and color Doppler in the prospective evaluation of
acute renal obstruction. Do they replace the intravenous urogram? Abdom Imaging. 1995; 20:58-63.
11. 24 Fielding JR, Steele G, Fox LA, Heller H, Loughlin KR. Spiral computerized tomography in the evaluation of acute flank pain: a
replacement for excretory urography. J Urol 1997; 157:2071-2073.
12. 25 Radermacher J. Internist 2003; 44:1413-1431.
13. 26 Sandhu C, Anson KM, Patel U. Urinary Tract Stones – Part I: Role of Radiological Imaging in Diagnosis and Treatment Planning.
Clin Radiol 2003; 58:415-421.
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
1998; 8:212-217.
15. 33 Sandhu C, Anson KM, Patel U. Urinary Tract Stones – Part II: Current Status of Treatment. Clin Radiol 2003; 58: 422-433.
16. 35 Smith RC, Rosenfield AT, Choe KA, et al. Acute flank pain: comparison of unenhanced-enhanced CT and intravenous urography.
Radiology 1995; 194:789-794.
17. 36 Sommer FG, Jeffrey RB, Rubin GD, et al. Detection of ureteral calculi in patients with suspected renal colic: value of reformatted
noncontrast helical CT. AJR 1995; 165:509-513.
18. 37 Smith RC, Verga M, McCarthy Sh, Rosenfield AT. Diagnosis of acute flank pain: value of unenhanced helical CT. AJR 1996;
166:97-101.
19. 47 Dalla Palma L, Pozzi-Mucelli R, Stacul F. Present-day imaging of patients with renal colic. Eur. Radiol 2001; 11:4-17.
20. 48 Kawashima A, Sandler CM, Boridy IC, Takahashi N, Benson GS, Goldman SM. Unenhanced Helical CT of Ureterolithiasis: Value
of the Tissue Rim Sign. AJR 1997: 168:997-1000.
21. 49 Heneghan JP, Dalrymple NC, Verga M, et al. Soft-Tissue “Rim” Sign in the Diagnosis of Ureteral Calculi with Use of Unenhanced
Helical CT. Radiol 1997; 202:709-711.
22. 50 Boridy IC, Nikolaidis P, Kawashima A, Goldman SM, Sandler CM. Ureterolithiasis: value of the tail sign in differentiating phleboliths
from ureteral calculi at nonenhanced helical CT. Radiology 1999; 211:619-621.
23. 51 Takahashi N, Kawashima A, Ernst RD, et al. Ureterolithiasis: Can clinical outcome be predicted with Unenhanced Helical CT?
Radiology 1998; 208:97-102.
24. 53 Bell TV, Fenlon HM, Davison BD, et al. Unenhanced helical CT criteria to differentiate distal ureteral calculi from pelvic phleboliths.
Radiol 1998; 207:363-367.
25. 57 Thomson JM, Glocer J, Abbott Ch, Maling Th. Computed tomography versus intravenous urography in diagnosis of acute flank
pain from urolithiasis: A randomized study comparing imaging costs and radiation dose. Australasian Radiology 2001; 45:291-297.
26. 69 Amis ES, Jr. Epitaph for the Urogram. Radiol 1999; 213:639-640.
27. 70 Denton ER, Mackenzie A, Greenwell T, Popert R, Rankin SC. Unenhanced helical CT for renal colic: is the radiation dose
justifiable? Clin Radiol 1999; 54: 444-447.
45

URINARY OBSTRUCTION – MRU AND CTU
Joern Kemper, MD; Claus Nolte-Ernsting, MD
Clinic of Diagnostic and Interventional Radiology
University Hospital Eppendorf – Hamburg, Germany
Urinary obstruction with hydronephrosis is a common outcome of many urologic diseases. A wide variety of
pathological processes, intrinsic and extrinsic to the urinary system, can cause urinary obstruction. Calculi,
neoplasms, infection, coagulopathy and inflammatory and fibrotic processes are important pathologies. Most
acute obstructive uropathies are associated with significant pain that alerts the clinician to the need for
appropriate diagnostic work-up and treatment. However, chronic urinary obstruction often requires a high
index of suspicion, which prompts an appropriate imaging modality that my confirm or rule out the presence
of obstruction.
Many imaging modalities have been used to evaluate patients with urinary obstruction. Historically,
intravenous urography (IVU) has been the primary method of imaging in these patients. Currently, the
examinations that are commonly used to evaluate patients with urinary obstruction include IVU,
ultrasonography (US), computed tomography (CT), magnetic resonance (MR) imaging, retrograde
ureterography and pyelography, cystoscopy, and ureteroscopy. Evaluation of patients with urinary
obstruction frequently requires several imaging modalities. Each offers its specific advantages. Both CT
urography (CTU) and MR urography (MRU) have evolved into important diagnostic tools in modern
uroradiology.
Magnetic resonance urography (MRU) has the potential to provide anatomical and functional information
about a possible obstructed urinary tract without nephrotoxic contrast media or radiation exposure 1, 2 . The
classic MR-urographic technique utilizes unenhanced, heavily T 2 -weighted turbo spin-echo sequences for
obtaining static fluid images of the upper urinary tract independent of the excretory renal function. T 2 -
weighted MR urograms have proved to be excellent in visualizing the dilated urinary tract, even in nonexcreting
kidneys. In addition, T 1 -weighted MRU reflects the excretory renal function and displays the urine
flow within the upper urinary tract after renal excretion of gadolineum chelate. Fast T 1 -weighted 3D gradientecho
sequences provide impressive urograms of both non-dilated and obstructed collecting systems in
patients with normal and moderately impaired renal function. Using these advantages, MRU has the potential
to be a valuable diagnostic tool in the assessment of obstructive uropathy especially in pediatric or post renal
transplant settings.
The introduction of multislice-computed tomography (MSCT), with its well known advantages has provided
the possibility to obtain thin axial images of the entire urinary tract in one breath-hold. This advance has had
a significant impact on imaging of the urinary tract. Application of MSCT to the collecting system during
urographic phase has been termed “CT-Urography” 3-8 . Consequently, CTU is also an excretory urography
like T 1 -weighted MRU. It can be combined with low-dose furosemide or saline for accelerated passage of
excreted contrast material making abdominal compresssion dispensable 4, 5, 9, 10 . The acquired volume
dataset allows the reconstruction of high-resolution multiplanar (MPR), maximum-intensity (MIP), and
average-intensity (AIP) images of the collecting system. It has the potential to provide a complete
assessment of the genitourinary tract. The outlined benefits of MSCTU also pose significant challenges in
terms of optimal imaging protocols and control the radiation exposure to the patient 11, 12 .
The aim of this lecture is to review the current technical principles and imaging protocols of MRU and CTU.
The imaging capabilities and the relative merits of these modalities in the evaluation of upper urinary
obstruction are discussed by means of clinical examples.
References
1. Nolte-Ernsting CC, Staatz G, Tacke J, Gunther RW. MR urography today. Abdom Imaging 2003; 28:191-209.
2. El-Diasty T, Mansour O, Farouk A. Diuretic contrast-enhanced magnetic resonance urography versus intravenous urography for
depiction of nondilated urinary tracts. Abdom Imaging 2003; 28:135-45.
3. Caoili EM, Cohan RH, Korobkin M, et al. Urinary tract abnormalities: initial experience with multi-detector row CT urography. Radiology
2002; 222:353-60.
4. McTavish JD, Jinzaki M, Zou KH, Nawfel RD, Silverman SG. Multi-detector row CT urography: comparison of strategies for depicting
the normal urinary collecting system. Radiology 2002; 225:783-90.
5. Nolte-Ernsting CC, Wildberger JE, Borchers H, Schmitz-Rode T, Gunther RW. Multi-slice CT urography after diuretic injection: initial
results. Rofo 2001; 173:176-80.
46

6. El-Ghar ME, Shokeir AA, El-Diasty TA, Refaie HF, Gad HM, El-Dein AB. Contrast enhanced spiral computerized tomography in
patients with chronic obstructive uropathy and normal serum creatinine: a single session for anatomical and functional assessment. J
Urol 2004; 172:985-8.
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
1:S74-86.
8. Mueller-Lisse UG, Mueller-Lisse UL, Hinterberger J, Schneede P, Reiser MF. Tri-phasic MDCT in the diagnosis of urothelial cancer.
Eur Radiol 2003; 13:B7.
9. Kemper J, Regier M, Begemann PG, Stork A, Adam G, Nolte-Ernsting C. Multislice computed tomography-urography: intraindividual
comparison of different preparation techniques for optimized depiction of the upper urinary tract in an animal model. Invest Radiol
2005; 40:126-33.
10. Caoili EM, Inampudi P, Cohan RH, Ellis JH. Optimization of multi-detector row CT urography: effect of compression, saline
administration, and prolongation of acquisition delay. Radiology 2005; 235:116-23.
11. Kemper J, Nolte-Ernsting C, Regier M, Begemann PGC, Stork A, Adam G. Multislice-CT-Urography (MSCTU): dose reduction with
regard to image quality. Eur Radiol 2004; 14:T2.
12. Nawfel RD, Judy PF, Schleipman AR, Silverman SG. Patient radiation dose at CT urography and conventional urography. Radiology
2004; 232:126-32.
URINARY OBSTRUCTION – RADIATION AND ECONOMIC ASPECTS
Fulvio Stacul
Istituto di Radiologia, Ospedale di Cattinara, Trieste, Italy
Unenhanced spiral CT (UHCT) is the new gold standard for imaging patients with renal colic, but radiation
dose and costs are a significant problem.
These two issues will be separately analysed.
UHCT- Radiation dose
The radiation issue is very significant in this clinical setting because we are often dealing with young patients
at significant life time risk for recurrent renal colics, that is for additional CT procedures.
It should be underscored that stone detection is the main goal of CT in these patients and this is a good
opportunity for dose reduction because of the high contrast between stones and adjacent soft tissues.
When using single-detector scanners (SDCT) the radiation dose delivered with CT was usually reduced
increasing the pitch. The higher is the pitch, the lower is the corresponding dose (i.e. increasing the pitch
from 1 to 1.5 corresponds to a dose reduction of 33%). The dose reduction is due to increased spacing,
which provides on the other side a lower image quality on the reconstructed images (however slice thickness
has a higher influence on the image quality).
Using imaging parameters on multi-detector-scanners (MDCT) that are similar to those used with SDCT can
result to greater dose exposures. It was reported (1) that studies using MDCT with thin collimations (ranging
from 1 to 3 mm) but with mAs setting similar to those used with SDCT, lead to an effective radiation dose
increased by a factor of 2-3, typically around 15 mSv (compared to a typical range of 4-7 mSv using SDCT).
Nickoloff and Alderson (2) reported that the dose is 30-50% higher with MDCT because of scan overlap,
because the tube is closer to the patient and because of more scattered radiations. The pitch can be
increased, but unfortunately on some MDCT units the tube current (mAs) is automatically increased to
maintain the same dose level if the pitch is increased. As a result the measured radiation dose is identical for
different pitch selections (3).
Therefore investigators using MDCT usually lowered the tube current (mAs) to lower the corresponding dose
(although image noise increases).
Many solutions were suggested to lower the radiation dose with MDCT, both with the goal of getting a dose
efficient scanner design (highest geometric efficiency, lowest overbeaming, low-noise data acquisition
system) and of an automatic dose control and display (automatic exposure control, dynamic dose
modulation). However initial decreases of mAs presets by the physician is the primary tool for radiation dose
reduction (it saves up to 90% of the dose) while attenuation based online tube current modulation is a
secondary tool (it saves up to 20% of the dose) (1).
The problem is to what extent we can reduce the dose keeping a high diagnostic accuracy. Hamm et al (4)
delivered with SDCT a mean effective dose at 70 mAs of 0.98-1.5 mSv and obtained a sensitivity of 96% and
a specificity of 97% considering stone detection. Tack et al (1) delivered with MDCT a mean effective dose at
30 mAs of 1.2-1.9 mSv and reported an accuracy of 93-98%. Therefore we can achieve a major radiation
dose reduction still keeping a high stone detection accuracy. Nevertheless there is concern regarding the
alternative and additional diagnoses that could be missed if the dose is lowered too much (5).
47

UHCT – Cost analysis
We analysed the cost of UHCT considering the activities performed within the Radiology Department (6). Our
cost identification analysis assessed the differential cost of this procedure, its common cost and its full cost.
The differential cost included equipment costs (depreciation and maintenance), variable costs (materials and
related services) and personnel costs (radiologist, radiographer). The common costs are all costs for
productive factors, within the Radiology Department, providing support services common to all investigations.
The full cost is the sum of the differential and the common cost. The differential cost of SDCT was 68.00 €
(equipment costs 12.20 €, variable costs 37.70 €, personnel costs 18.10 €), the common cost was 6.00 € and
the resulting full cost was 74.00€. As a comparison, the full costs of the plain film of the abdomen, of
ultrasonography of the urinary tract and of intravenous urography were 15.61, 28.60 and 80.90 €
respectively.
It is interesting that the full cost of SDCT is heavily dependent on the variable costs and in particular on the
cost deriving from the number of shots of the X-ray tube. We considered the full cost of a 16-slice MDCT as
well, which was 71.65 €. The higher purchase cost (when compared to our SDCT) was counterbalanced by
the longer forecasted life of the X-ray tube.
The results we achieved are a photograph of our Department at one point in time and cannot be simply
exported to other Radiology Departments, because of multiple variables (purchase cost, number of films,
personnel salaries, organizational choices....). Therefore the methodology we used can be considered a tool
for similar cost analyses in other environments.
References
1. Tack D, Sourtzis S, Delpierre I et al (2003) Low-dose unenhanced multidetector CT of patients with suspected renal colic. AJR 180:
305-311.
2. Nickoloff EL, Alderson PO (2001) Radiation exposure to patients from CT: reality, public perception and policy AJR 176: 285-287.
3. Mahesh M, Scatarige JC, Cooper J et al (2001) Dose and pitch relationship for a particular multislice CT scanner AJR 177: 1273-1275.
4. Hamm M, Knopfle E, Wartenberg S et al (2002) Low dose unenhanced helical computerized tomography for the evaluation of acute
flank pain. J Urol 167: 1687-1691.
5. Kats DS, Venkataramanan N, Napel S et al (2003) Can low-dose unenhanced multidetector CT be used for routine evaluation of
suspected renal colic? AJR 180: 313-315.
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:
1620-1627
INVESTIGATION OF MICROSCOPIC HEMATURIA: A NEPHROLOGISTS’S
PERSPECTIVE
Jürgen Floege MD
Div. Nephrology, University of Aachen, Germany; juergen.floege@rwth-aachen.de
Asymptomatic, isolated microscopic hematuria (AMH) is very common in the general population and, given
its prevalence, represents a diagnostic dilemma since extensive work-up is not justified in the majority of
patients. From a nephrological point of view the following issues will be presented:
1. AMH detection by dipstick is as sensitive as urinary sediments to predict urogenital pathology;
2. Every dipstick-positive proteinuria accompanying AMH needs to be evaluated further, since it usually
indicates significant glomerular/renal pathology and usually does not result from „urologic“ bleeding;
3. AMH needs to be evaluated further by phase-contrast microscopy and/or determination of mean urinary
red cell volume (the relative value of these two methods is unknown);
4. About 50% of patients with AMH that is not explained by urologic causes exhibit glomerular
abnormalities (i.e. the prognosis of AMH in general is obviously good);
5. AMH is not a good predictor of urogenital malignancy but the risk of renal failure is increased 2-fold in
patients with AMH;
6. 5-10 years after the first diagnosis of AMH a significant percentage of patients will develop hypertension,
proteinuria and/or GFR-reduction. Annual follow-up should therefore be done routinely.
48

URINARY BLEEDING:
IMAGING FOR SUSPECTED BENIGN AND MALIGNANT DISEASES
Elaine M. Caoili, MD and Richard H. Cohan, MD
University of Michigan, USA
Introduction
Traditionally, excretory urography with or without ultrasonography has been utilized as the initial imaging
approach to evaluate patients with hematuria. However, over the past few years, CT urography (CTU) has
emerged as the best single imaging test for comprehensive evaluation of the urinary tract. While CT is
acknowledged to be superior to excretory urography (EU) and ultrasound (US) in its ability to detect and
characterize renal masses [1] and to detect urinary tract calculi [2], it is now known that CTU is also accurate
when evaluating the renal collecting systems, ureters, and bladder, with a sensitivity in detecting
abnormalities that rivals, if not exceeds that of EU and even retrograde pyelography [3-7]. MR urography
(MRU) is also being performed with increasing frequency, but is often reserved for patients who are not able
to receive iodinated contrast material, such as those who have had prior reactions or those who have
compromised renal function.
CT urographic technique
While many different CTU protocols are being used, the overwhelming consensus now is that the renal
collecting systems, ureters, and bladder are best assessed when a large number of thin (1.25 mm or less)
section axial CT images are acquired during renal excretion of intravenously administered contrast material.
Support for other protocols involving combinations of standard CT and conventional radiography or CT and
CT digital scout images (in lieu of any excretory phase axial images) has waned. Many CTU protocols
currently include an unenhanced series (usually performed as a standard “renal stone” CT). In addition,
nephrographic phase images are obtained either during a subsequent series of image acquisitions obtained
several minutes before the excretory phase images [7, 8] or combined with the excretory phase series (in
which case the contrast material must be administered as a split bolus, with the first dose utilized to evaluate
the renal collecting systems and ureters and a second delayed dose utilized to evaluate the renal
parenchyma at the same time [9]). There have been wide variations in the timing of both nephrographic and
excretory phase image acquisition, with differences in the latter times ranging between a few minutes and 15
minutes.
CTU studies contain large numbers of axial images (often more than 1,000), which can take time and effort
to review. The number of images can be reduced by reconstructing the data into thicker section images to
be reviewed by the radiologist at the time of study interpretation, but using thinner section reconstructed
images as source images for multiplanar reformatted and three-dimensional images that are created. For
example, at our institution, on 16-row scanners, excretory phase images are reconstructed at 1.25 mm
thickness and 0.625 mm intervals for reformatting, but at 2.5 mm thickness and 1.25 mm intervals for image
review.
Some institutions also supplement axial excretory phase images with excretory phase digital scout
radiographs [10]. The rationale for obtaining these images is that they offer the opportunity to visualize
segments of the ureters that may not be opacified during axial image acquisition (although not in as much
detail).
Most institutions performing CTU create coronal reformatted images and/or three-dimensional (3D) images
(which can be obtained using volume rendering, average intensity projection or maximum intensity projection
algorithms) [5]. The three-dimensional images are usually created in the coronal anteroposterior and both
coronal oblique planes. As such, they effectively demonstrate the urinary tract in planes similar to that
demonstrated by EU. However, they usually provide little additional information to that of the source axial
images. In fact, in one study, when only three-dimensional reconstructed images were reviewed, 18 of 24
detectable upper tract uroepithelial neoplasms could not be identified [11].
49

MR Urographic Technique
MRU of dilated renal collecting systems and ureters can be performed using heavily T2-weighted sequences,
which allows for visualization of dilated, usually obstructed, collecting systems. In comparison, non-dilated
renal collecting systems and ureters are best assessed by administering a gadolinium-based MR contrast
agent and then obtaining T1-weighted images. Even then, it is helpful to administer low-dose furosemide
(often 10 mg) to increase diuresis and improve visualization of the urinary tract [12, 13].
CTU Image review
CTU images must be reviewed utilizing wide windowing. Indeed, many small lesions will be missed if images
are reviewed only at standard soft tissue windows [14]. Small urothelial masses and filling defects can be
obscured by the dense, high attenuation, contrast material in the renal collecting systems and ureters when
soft tissue windowing is employed utilized.
Preliminary results using CT and MR urography
Results with CTU and MRU are encouraging. A variety of collecting system and ureteral abnormalities have
been detected (examples of which will be presented in these talks) [7].
Detection of benign abnormalities (R. Cohan)
Of the first 1,077 CT urograms performed at our institution, many diagnoses of benign upper tract
abnormalities, once thought to be undetectable on CT and MR, have been made. Excluding urolithiasis,
these have included 35 congenital abnormalities, such as horseshoe kidneys, 18 caliceal diverticula, 11
patients with papillary necrosis, eight patients with renal tubular ectasia, and one patient with pyelo-ureteritis
cystica. These abnormalities can are usually best detected on axial and reformatted images reviewed
utilizing wide windows. In addition, a new benign ureteral abnormality has been described: diffuse urothelial
wall thickening. This entity, which can be caused by pyelitits or ureteritis, is easily detected on axial CT or
MR images, but not well seen on 3D reconstructed images or on conventional excretory urography, because
it may not produce any intraluminal abnormality. To date, such benign circumferential urothelial wall
thickening has been detected on CTU and MRU in patients who have had prior instrumentation (including
insertion of still indwelling ureteral stents), and in patients with infectious ureteritis, retroperitoneal fibrosis,
and amyloidosis. It is important to note that this appearance can also be produced by urothelial malignancy.
The most common CTU or MRU detected benign bladder abnormality (producing hematuria) has been
urothelial wall thickening, usually resulting from inflammation (cystitis) or outlet obstruction. Such thickening
is usually mild and fairly uniform.
Detection of malignancies (E. Caoili)
The greatest benefit of CT and MR urography has been in its detection of urothelial neoplasms [i.e. - 15]. In
one series, 24 of the first 27 subsequently diagnosed upper tract uroepithelial neoplasms were detected on
CTU, several of which were quite small (measuring only a few mm in size) [11]. This includes a few patients
whose cancers presented as diffuse circumferential ureteral wall thickening in the absence of ureteral
dilatation, ureteral stricture, or filling defects [5, 11]. This newly recognized CT or MR manifestation would
likely not produce any abnormality on EU, since the latter only demonstrates excreted contrast material in the
renal collecting system and ureteral lumen. This finding is not specific for urothelial cancer. It has also been
seen with benign entities as well as other malignancies, such as lymphoma.
CTU and MRU are also very accurate in detecting bladder neoplasms. Of the first 44 bladder neoplasms in
patients referred for CTU, 37 were prospectively identified, and only two were found to be retrospectively
undetectable. While the ability of CTU or MRU to identify bladder pathology is not as important as its ability
to evaluate the upper tracts, given the widespread use of cystoscopy, it may be possible to use CTU in some
instances as a screening tool, helping to determine which patients at high risk for developing bladder
neoplasms should undergo cystoscopy.
Technical Limitations
No matter what specific technique is employed, the most common CTU and MRU interpretive problem
relates to non opacification of ureteral segments, a problem which can be observed in up to 25-33% of
patients with non-dilated non-obstructed urinary tracts [16]. When the non opacification is due to delayed
excretion resulting from urinary tract obstruction, the cause of the obstruction, whether it be a calculus,
50

tumor, or stricture, is usually readily identified. In contrast, when there is non opacification of a portion of a
non-dilated ureter, a small non-obstructing lesion could be missed in the non-opacified segment. One
solution to this problem is to obtain repeat scans through the unopacified regions until opacification occurs.
Another is to supplement the axial images with digital scout radiographs [10]. Yet a third is to obtain no
additional imaging, but, instead, to assume that such segments do not harbor any pathology, with the
understanding that in very rare instances a tiny non obstructing lesion will not be identified.
Other considerations
CTU and MRU are now being requested more frequently by clinicians. For example, at our institution, the
number of requested CTUs each day now exceeds the number of requested EUs.
CTUs and MRUs contain hundreds of axial images and are more time-consuming to interpret than are EUs.
The most obvious solution to this potential problem is to devise a way in which a smaller number of images
can be reviewed with the same accuracy as occurs with axial image review. As previously mentioned,
standard 3D reconstruction techniques have already been found to be inadequate [11]. More recently,
thinner section 3D reconstructions have also been found to be insensitive in identifying uroepithelial
neoplasms [17]. Another approach must be considered. Recently, we assessed the utility of coronal
reformatted images (obtained using the same image thickness and reconstruction intervals as the axial
images). Since each image covers a much larger part of the renal collecting systems and ureters than does
an axial image, the number of excretory phase images that must be reviewed can be reduced dramatically,
from 500-700 to 80-120 [17]. Not surprisingly, the time required for coronal reformat image review is less
than that needed for axial image review [14].
Another important problem unique to CTU (compared with MRU) is increased patient radiation exposure.
Utilizing a three-phase CTU protocol, CTU radiation dose has been observed to exceed that of a 10-15 film
EU by a factor of 50% [8]. When the split-bolus technique is employed radiation exposure from the two
studies is nearly the same. To minimize radiation dose to the most radiation susceptible patients, some have
suggested that use of CTU be restricted to older patients (> 40 years of age) who are at high risk for urinary
tract pathology, particularly malignancy [5]. Others have suggested that CTU should be used for all patients,
regardless of age [i.e. - 4]. Most investigators agree, however, that further attempts must be made to reduce
patient radiation exposure (by utilizing low mA technique on noncontrast scans, for example).
Summary
CTU and MRU have now begun to replace EU as the optimal study for evaluation of the kidneys, renal
collecting systems, ureters, and bladder in patients with hematuria. CTU can demonstrate tiny benign and
malignant abnormalities once thought to be undetectable by CT. Although there are a number of variations in
technique across the country, these are diminishing. No matter what technique is employed, the greatest
interpretive problem is the occasional lack of opacification of non-dilated ureteral segments. Other issues that
also must be addressed are the increased number of generated images and the increased time required for
study interpretation. Efforts to reduce the number of images that must be reviewed are underway. Attempts
to reduce patient radiation exposure must also continue. Despite these concerns, the great success already
achieved by CTU and (to a lesser extent) MRU will serve to facilitate the demise of the EU in the very near
future.
References
1. Jamis-Dow CA, Choyke PL, Jennings SB, et al. Small (< 3-cm) renal masses: detection with CT versus US and pathologic correlation.
Radiology, 1996;198:785-788.
2. Smith RC, Verga M, McCarthy S, Rosenfield AT. Diagnosis of acute flank pain: value of unenhanced CT. AJR 1996;166:97-101.
3. McCarthy CL, Cowan NC. Multidetector CT urography (MD-CTU) for urothelial imaging. Radiology 2002; 225(P):237.
4. Lang EK, Macchia RJ, Thomas R, et al. Computerized tomography tailored for the assessment of microscopic hematuria. J Urol
2002;167:547-554.
5. Caoili EM, Cohan RH, Korobkin M, Platt JF, Francis IR, Faerber GJ, Montie JE, Ellis JH. Urinary tract abnormalities: initial experience
with multi-detector row CT urography. Radiology 2002;222:353-360.
6. O’Malley ME, Hahn PF, Yoder IC, Gazelle GS, McGovern FJ, Mueller PR. Comparison of excretory phase, helical computed
tomography with intravenous urography in patients with painless hematuria. Clin Radiol 2003;58:294-300.
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.
8. Nawful RD, Judy PF, Schleipman AR, Silverman SG. Patient radiation dose at CT urography and conventional urography. Radiology
2004; 232:126-132.
51

9. Chow LC, Sommer FG. Multidetector CT urography with abdominal compression and three-dimensional reconstruction. AJR 2001;
177:849-855.
10. Sudakoff GS, Guralnick M, Langenstroer P, et al. AJR 2005; 184:131-138.
11. Caoili EM, Inampudi P, Cohan RH, Ellis JH, Korobkin M, Platt JF, Francis IR. MDCTU of upper tract uroepithelial malignancy. In
press, AJR, 2005.
12. Kawashima A. Glockner JF, King, BF. CT urography and MR urography. Radiol Clin North Am. 2003; 41:945-61.
13. Nolte-Ernsting CC, Staatz G, Tacke J, Gunther RW. MR urography today. Abdom Imaging. 2003; 28:191-209.
14. Hilmes MA, Caoili EM, Cohan RH, Ellis JH, Nan B, Platt JF. Evaluation of the ability of individual phases of multi-detector CT
urography and different windowing to detect urinary tract pathology. Presented at the 29 th annual scientific meeting of the Society of
Uroradiology, March 6, 2004.
15. Mueller-Lisse UG, Mueller-Lisse UL, Hinterberger J, Schneede P, Reiser MF. Tri-phasic MDCT in the diagnosis of urothelial cancer.
Eur Radiol 2003;13(S1):146-147.
16. Inampudi P, Caoili EM, Cohan RH, Ellis JH, Korobkin M, Platt JF, Francis IR. Effect of compression, saline administration, and
prolonging acquisition delay on images obtained during multidetector CT urography (MDCTU). AJR 2003;180(S):71.
17. Feng FY, Caoili EM, Cohan RH, et al. Coronal vs standard axial image review CT urography. Presented at the 30 th annual scientific
meeting of the Society of Uroradiology, February 27, 2005.
IMAGING THE PATIENT WITH HEMOSPERMIA
Parvati Ramchandani, MD
University of Pennsylvania, Medical Center
Blood in the ejaculate
Hematospermia or Hemospermia
Objectives
• review normal anatomy of the ejaculatory tract
• review the imaging findings of pathologies that cause hematospermia
• discuss management strategies
Hematospermia
• Peak incidence in 30-40 yr olds
• >80% have repeated episodes
• Brownish or red discoloration of ejaculate
Semen production
(and therefore blood in ejaculate)
• From multiple sources
- testes, epidydimis, vas deferens,
- seminal vesicles and prostate
• Majority of semen is from seminal vesicles and prostate
Ejaculatory Tract Anatomy
T2 W Coronal MR
52

Ejaculatory Tract Imaging
• Vasoseminal vesiculography
• TRUS
• MRI - modality of choice
Vasoseminal Vesiculography “Vasogram”
• Best study to demonstrate lumen of vas deferens
• No role in hematospermia evaluation
• Performed only in infertile men with suspected obstruction of vas deferens
Normal VD
Occluded bilat - post hernia repair
TRUS
• 5-7.5 MHZ transducers
• SV are symmetrically hypoechoic, less echogenic than prostate
• Non dilated vas deferens and ejaculatory ducts are not consistently demonstrated
MRI of Ejaculatory Tract
- Endorectal coil (E-coil) MRI provides best anatomic resolution
MRI of Seminal Vesicle
T1W- intermediate SI
T2W- bright convoluted tube
MRI of Seminal Vesicle
T2W- bright convoluted tube superior to prostate
blood low SI, depending on age
MRI of Vas Deferens
Ampulla of vas is dark on T2W images due to thick muscular wall
53

Seminal Vesicle Pathology
Congenital – agenesis, cysts
Inflammatory, including calculi
Neoplasms
Congenital Seminal Vesicle Pathology
• Frequent association with urinary tract anomalies
because seminal vesicles, vas deferens and ureter are all derived from mesonephric (Wolfian) duct
Seminal Vesicle Cysts and Agenesis
• Association Ipsilateral renal anomalies very common agenesis, hypoplasia, ectopic ureteral insertion
• Association with autosomal dominant polycystic kidney disease
Seminal Vesicle Cysts
• Association with autosomal dominant polycystic kidney disease
• Present in young adulthood
• Cysts contain viscous brownish fluid with dead sperm UNILOCULAR
Cystic Lesions in Male Pelvis
• SV cyst
• Vas deferens cyst
• Mullerian duct cyst
• Prostatic utricle cyst
• Ejaculatory duct cyst
• Prostatic cysts
Radiographics; 1990
Stones and Inflammatory Disease
Inflammatory Diseases
• Seminal vesiculitis usually associated with prostatitis
• May present with hematospermia
• Clinically obvious
• Can progress to abscess
• Predisposing factors- Instrumentation, diabetes, UTI
Hematospermia and Neoplasms
• Seminal vesicle
- usually secondary involvement by prostate, rectal, or bladder cancer
- primary tumors are are
• Prostate Ca can present with hematospermia
Metastatic Disease of SV
• E- coil MR
• T2W images
• Bright intensity of normal tubules replaced by low Intensity foci and tubular thickening
54

Hematospermia
Men < 40 years
• usually due to inflammation in prostate, SV, epidydimis, or testicle
• SV cysts or calculi
• Rarely malignant or benign tumors e.g. urethral hemangioma
Hematospermia
• Men > 40 years
• Benign causes predominate
• 5-10% may be due to CA prostate, bladder or SV
Hematospermia
Work up if
• Persistent
• Associated with pain or hematuria
• E-coil MR is imaging modality of choice
Conclusion
• Imaging is useful in evaluating patients with hematospermia and suspected ejaculatory tract abnormality
• Both TRUS and MRI play a role in the management of these patients
References:
1. Schiff JD. Hematospermia. www.emedicine.com/med/topic3466.htm, 11.7.02
2. Nghiem HT, Kellman GM, Sandberg SA, Craig, BM. Cystic lesions of the prostate. Radiographics 1990; 10: 635-650
3. Weidner W, Schumacher JF, Schiefer HG, Meyhofer W. Recurrent haemospermia—underlying urogenital anomalies and efficacy of
imaging procedures. British J of Urology 1991; 67: 317-323
4. Alpern MB, Dorfman RE, Gross BH, Gottlieb CA, Sandler MA. Seminal vesicle cysts: association with adult polycystic kidney disease.
Rdiology 1991; 180: 79-80
5. Ramchandani P, Torigian D. Evaluating the male with hematospermia. Abdominal Imaging (In Press)
6. Ganabathi K, Chadwick D, Feneley RCL, Gingell JC. Haemospermia. British J of Urology 1992; 69: 225-230
7. Maeda H, Toyooka N, Kinukawa T, et al. Magnetic resonance imaging of hematospermia. Urology 1993; 41: 499-504
8. Worischeck JH, Pasrra RO. Chronic hematospermia: assessment by transrectal ultrasound. Urology 1994; 43: 515-520
9. Ramchandani P, Banner MP, Pollack HM: Imaging of Seminal Vesicles. Seminars in Roentgenology 1993; 28: 83-91.
ARTERIAL EMBOLIZATION IN EMERGENCY URORADIOLOGY
Tarek A. El-Diasty, MD
Department of Radiology, Urology and Nephrology Center, Mansoura University
Mansoura – Egypt
Several traumatic and neoplastic causes may lead to significant renal hemorrhage and sever hematuria.
Transcatheter selective arterial embolization is an effective parenchymal sparing procedure in management
of life threatening renal hemorrhage.
Traumatic injury to the renal vasculature is a well recognized and most worrisome complication of
percutaneous renal procedures such as renal biopsy, percutaneous nephrostomy (PCN) and percutaneous
nephrolitomy (1) . The most common causes of hemorrhage post percutaneous renal procedures are
pseudoaneurysms and areterio-venous fistulas (2) . Percutaneous intra-arterial embolization is the treatment of
choice, which not only is life saving but ultimately a kidney sparing procedure. Embolization of the peripheral
vessels is preferable to frank exploration, even in a transplanted kidney (3,4) .
Treatment of angiomyolipomas beneficial is in limiting the sometimes life-threatening complications of
spontaneous bleeding (5) .
55

Therapeutic embolization of the bladder may be an effective method of controlling persistent hematuria
caused by radiation cystitis, chemical cystitis, or direct tumour invasion of the bladder in patients who are
unresponsive to intravesical instillation of therapeutic agents or surgery (6,7) . Selective embolization of the
anterior division of the hypogastric artery is required bilaterally, even if the bleeding can be predominantly
localized to one wall of the bladder (8) .
High flow arteriogenic priapism is uncommon and usually occurs after trauma to the genitoperineal area.
Angiography in this case illustrated the causative arteriovenous fistulae or pseudoaneurysms. Treatment
consists of superselective embolization of the feeding artery resulting in detumescene (9) .
In this lecture, the techniques, types of embolic material and results of selective embolization in different
urologic emergencies will be addressed.
References
1. Rao A, Pandey UC. Transarterial embolization of iatrogenic renal vascular injury. Ind J Radiol Imag 2004; 14, 3: 303-307.
2. Kessaris D, Bellman G, Pardalidis N, Smith A. Management of hemorrhage after percutaneous renal surgery. J Urol 1995; 153: 604-
608.
3. Patterson D, Segura J, Leroy A, Benson R, May G. The etiology and treatment of delayed bleeding following percutaneous lithotripsy.
J Urol 1989; 133: 447-451.
4. Orans P, Zajko A. Angiography and interventional aspects of renal transplantation. Radiol Clin North Am 1995; 33: 461-471.
5. Hamlin JA. Renal angiomyolipomas: long-term follow-up of embolization for acute hemorrhage. Can Ass Rad J 1997; 48: 191-198.
6. Lang EK. Transcatheter embolization of pelvic vessels for control of intractable hemorrhage. Radiology 1981; 140: 331-339.
7. Mcivor J, Williams G, Greswick Southcott R. Control of sever vesicle hemorrhage by therapeutic embolization. Clin Radiol 1982; 33:
561-567.
8. Ward JF, velin TE. Transcatheter therapeutic embolization of genitourinary pathology. Rev Urol 2000; 2 (4): 236-245.
9. Gujral S, Mac Donagh RP, Cavanagh PM. Bilateral superselective arterial microcoil embolization in delayed post-traumatic high flow
priapism postgrad. Med J 2001; 77: 193-194.
UROGENITAL EMERGENCIES IN FEMALE PATIENTS:
THE OBSTETRICIAN’S PERSPECTIVE
Tanja Premru-Srsen,
tanja.premru@guest.arnes.si
University Department of Obstertics and Gynecology
University Medical Centre, Ljubljana, Slovenia
Postpartum hemorrhage remains a major cause of maternal morbidity and mortality throughout the world (1).
In a review of maternal mortality statistics from 1980-1985, the Maternal Mortality Collaborative reported 11
% of all deaths (from both direct and indirect causes) being caused by hemorrhage (2). In a Center for
Disease Control (CDC) citation from late 1970s, hemorrhage was a direct cause of death in 13.4 % of cases
(3). Other authors report this number may be as high as 28 % (4.5). What remains a concern is that despite
increasing technologic advances in the hospital setting, progress in identification of at risk patients remains
limited. In a report published in 1996 in London by the Confidential Enquiry into Maternal Deaths, 90 % of
maternal mortality as a result of intractable hemorrhage was deemed to have been preventable.
The definition of obstetric hemorrhage varies. Overall, excessive blood loss is considered to be greater than
500 ml by completion of the third stage of a vaginal delivery or 1000 ml after cesarean section (6). However,
most practitioners usually significantly underestimate blood loss and these criteria do not include significant
antepartum bleeding. A better definition may be obstetric bleeding which places the patient at risk for
hemodynamic instability (7). Severe obstetric hemorrhage is defined as estimated blood loss greater than
1500 ml, peripartum fall in hemoglobin concentration > 40 g/l or acute transfusion of > 4 U of blood (8).
Treatment is aimed at eradicating the source of bleeding while attempting to maintain intravascular volume to
preserve perfusion and oxygenation (9).
In the developed world, efforts to reduce maternal morbidity and mortality caused by obstetric hemorrhage
need to focus on identification of at risk patients and establishing management protocols. In addition,
extensive preoperative planning often needs to be implemented in caring for the most at risk patients,
56

enabling the optimal use of technologic advances such as magnetic resonance imaging (MRI) in diagnosis of
placenta accreta and of pelvic vessel embolization to control significant bleeding.
Postpartum hemorrhage is a frequent condition, whose incidence in the literature varies between 7 and 24 %
(1.10). Potential causes of hemorrhage include abnormal placentation, placental abruption, uterine rupture,
uterine atony, retained placenta, lower gential tract injuries, uterine inversion, and coagulopathies, uterine
atony and abnormal placentation/adherence being the major causes of primary postpartum hemorrhage. In
most cases, primary postpartum hemorrhage can be managed with conservative treatment involving
bimanual compression, uterine or vaginal packing and administration of uterotonic drugs (3,11). In case of
persistent bleeding, vascular ligation or hysterectomy may be required with risk of surgical complications,
including infection, bleeding and ureteral injury, and complications of general anaesthesia.
The development of interventional radiology has offered a new approach for the management of persistent
postpartum hemorrhage. In 1979, the first transcatheter embolization was performed in a patient with
postpartum hemorrhage after hysterectomy and vascular ligation (12, 13). Since then, many publications
have shown the usefulness of this procedure, whose success rate is around 90 % (14 -16). The incidence of
failure is approximately 5 % (17), of which abnormal placentation corresponds to more than 50 % (18-20).
The success rate of uterine artery embolization for management of abnormal placentation with postpartum
hemorrhage was reported to be 62 – 71 % in the literature (18, 19).
In some cases as in placenta previa/accreta abnormal adherence could be diagnosed antepartum by gray
scale ultrasound, color Doppler and MRI (3). Postpartum hemorrhage in such cases could be prevented by
multidisciplinary approach including also the interventional radiologist for possible preoperative arterial
embolization catheter placement. Ballon catheters can first be used to generally tamponade the area, and if
necessary can then be used to specifically embolize the vessel noted to have extravasation of blood (21).
Treatment of placenta accreta conservatively by prophylactic bilateral uterine artery embolistaion and leaving
in place the placenta that is partially or totally adhered to the myometrium has been reported successful in
reducing the rate of hysterectomy in such cases (18, 22).
Complications from uterine artery embolisation have likewise become more apparent as case reports have
been published and as resultes from larger case series have become available. Reported complications
mostly from uterine artery embolization of uterine fibroids include infection, absceses, sepsis, permanent
amenorrhea, labial necrosis, focal bladder necrosis, vesicouterine fistula, uterine wall defects, groin
hematoma, pulmonary emboli, and, rarely death (23). Overall complication rate reported was 5 % (24). The
loss of ovarian function has been reported to be as high as 14 % with uterine artrey embolization (25).
Approximately 50 cases of pregnancy have been reported in patients who have undergone elective uterine
artery embolisation. Analysis of these 50 cases shows a 22 % rate of spontaneous abortion, a 17 % rate of
malpresentation, a 7 % rate of small for gestational age infants, a 28 % rate of premature delivery, a 58 % of
cesarean delivery rate, and a 13 % rate of postpartum hemorrhage (26). Reported rates in the general
population for these events are lower except for small for gestational age infants which is higher (6, 27).
Embolization of uterine arteries, used for more than 25 years to control persistent postpartum hemorrhage,
has found an important role in the therapeutic arsenal of modern obstetrics. It should be used as soon as the
obstetrician judges the primary measures used for management of postpartum hemorrhage to be ineffective.
It could be used in all cases before surgery, because it does not preclude later surgery. It does not require
general anaesthesia, is not disturbed by coagulation disorders, and is reproducible. Its main advantage is to
preserve fertility. This technique requires the presence of an on-call radiologist familiar with interventional
radiology techniques. The possibility of offering this technique to all women after delivery could become one
of the challenges for the treatment of severe postpartum hemorrhage. This requires women at risk for
postpartum hemorrhage to be sent to the centers with possibility of interventional radiology.
Literature
1. Gibert L, Porter W, Brown VA. Postpartum hemorrhage: a continuing problem. Br J Obstet Gynaecol 1987; 94:67-71.
2. Rochat RW, Koonin LM, Atrash HK, et al. Maternal mortality in the United States: report from the Maternal Mortalita Collaborative.
Obstet Gynecol 1988;72:91-97.
3. Shevell T, Malone FD. Management of obstetric hemorrhage. Seminars Perinatol 2003; 27:86-104.
57

4. Bonnar J. Massive obstetric hemorrhage. Bailliere’s Clin Obstet Gynaecol 2000; 14:1-18.
5. Coueret Pellicier M, Bouvier Colle MH, Salavane Bet le groupe MOMS. Les causes obstétricales de décès expliquent-elles les
differences de mortalité maternelle entre la France et l’Europe? J Gynecol Obstet Biol Reprod 1999;28:62-8.
6. American College of Obtetricians and Gynecologists. Postpartum hemorrhage. ACOG educational bulletin number 234. Washington:
American College of Obtetricians and Gynecologists, January 1998.
7. Mason B. Postpartum hemorrhage and arterial embolisation. Curr Opin Obstet Gynecol 1998;10:475-9.
8. Waterstone M, Bewley S, Wolfe C. Incidence and predictors of severe obstetric morbidity: case-control study. BMJ 2001;322:1089-94.
9. Hunter SK, Weiner CP. Obstetric hemorrhage. In Repke JT, eds: Intrapartum obstetrics. Boston: Churchill Livingstone Inc., 1996;pp
203-22.
10. Newton M, Mosey LM, Egli GE, Gifford WB, Hull CT. Blood loss during and immediately after delivery. Obstet Gynecol 1961; 17:9-18.
11. Hebert WP, Afalo RC. Management of pos-tpartum hemorrhage. Clin Obstet Gynecol 1984:27:139-45.
12. Brown BJ, Heaston DK, Poulson AM, Gabert HA, Mineau DE, Miller FJ. Uncontrollable postpartum bleeding: a new approach to
hemostasis through angiographic arterial embolization. Obstet Gynecol 1979; 54:361-5.
13. Heaston DK, Mineau DE, Brown BJ, Miller FJ. Transcatheter arterial embolization for controle of persistent puerperal hemorrhage after
bilateral surgical hypogastric artery ligation. AJR Am J Roentgenol 1979; 133:152-4.
14. Tourné G, Collet F, Seffert P, Veyret C. Place of embolization of uterine arteries in the management of post-partum hemorrhage: a
study of 12 cases. Eur J Obstet Gynaecol Reprod Biol 2002; 110:29-34.
15. Jander HP, Russinovich NAE. Transcatheter Gelfoam embolization in abdominal. Radiology 1980:136:337-44.
16. Sergent F, Resch B, Verspyck E, Rachet B, Clavier E, Marpeau L. Intractable postpartum hemorrhages: where is the palce of vascular
ligatons, emergency peripartum hysterectomy or arterial embolization? Gynecol Obstet Fertil 2003; 32:320-9.
17. Badawy SZA, Etman A, Singh M, Murphy K, Mayelli T, Philadelphia M. Uterine artery embolization: the role in obstetrics and
gynecology. J Clin Imag 2001; 25:288-95.
18. Descargues G, Douvrin F, Degre S, Lemoine JP, Marpeau L, Clavier E. Abnormal placentation and selective embolization of the
uterine arteries. Eor J Obstet Gynecol Reprod Biol 2001;99:47-52.
19. Pelage JP, Le Dref O, Mateo J, Soyer P, Jacob D et al. Life threatening primary postpartum hemorrhage: treatment with emergency
selective arterial embolization. Radiology 1998;208:359-62.
20. Pelage JP, Le Dref O, Jacob D, Soyer P, Herbreteau D et al. Selective arterial embolization of the terine arteries in the management
of intractable post-partum hemorrhage. Acta Obstet Gynecol Scand 1999; 78:698-703.
21. Hansch E, Chitkara U, McAlpine J et al. Pelvic arterial embolization for controle of obstetric hemorrhage: a five years experience. Am J
Obstet Gynecol 1999; 180:1454-60.
22. Kayem G, Pannier E, Goffinet F, Grangé G, Cabrol D. Fertility after conservative treatment of placenta accreta. Fertil Steril 2002;
78:637-8.
23. American College of Obtetricians and Gynecologists. Uterine artery embolization. ACOG educational bulletin number 293.
Washington: American College of Obtetricians and Gynecologists, February 2004.
24. Spies JB, Spector A, Roth AR, Baker CM, Mauro L, Murphy-Skrynarz K. Complications after uterine artery embolization of
leiomyomas. Obstet Gynecol 2002:100:873-80.
25. Chrisman HB, Saker MB, Ryu RK, Nemcek AA Jr, Gerbie MV, Milad MP et al. The impact of uterine fibroid embolization on
resumption of menses and ovarian function. J Vasc Interv Radiol 2000; 11:699-703.
26. Goldberg J, Pereira L, Berghella V. Pregnancy after uterine artery embolization. Obstet Gynecol 2002; 100:869-72.
27. Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics – normal and problem pregnancies. 4 th ed. New York: Churchill Livingstone Inc.,
2002.
UROGENITAL EMERGENCIES IN FEMALE PATIENT:
GYNAECOLOGIC ASPECT
Adolf Lukanovic
Department of Gynecology and Obstetrics,
University Medical Centre, Ljubljana, Slovenia
Key words: urogenital radiology, imaging in urogynecology, modern perspective
Abstract
Background: The aim of this paper is to present the modern approach to different pathologies in everyday
clinical practice of any gynecologist. Special interest is given to the diagnostic pitfalls. Radiology imaging
techniques are beccomming of key importance for exact diagnostic protocol in all modern settings. They
serve as the basis for good therapeutic outcomes.
Conclusion: Undoubtless the future development in the diagnostic armamentarium of urogynecology imaging
will bring new possibilities for treatments. By keeping in mind these principles outlined in the article the care
provider will be able to achieve the desired result of the treatment while minimizing intra and postoperative
complications.
58

Introduction
There is a variety of several possibilities to use all kinds of imaging techniques in the field of urogynecology.
The radiologists have now more and more modalities from which to choose a rational approach to image the
female genital organs and the neighbouring organs of the pelvic floor. However as new diagnostic
possibilities arise, even they are new and sophisticated it does not mean one should ignore an older »low
tech« procedure. But the advantages are not only in better diagnosing; new »hig tech« radiologic procedures
are saving lives. This point is perhaps best understood by the enthusiasm of the participants in the recent
radiological meetings worldwide. Obviously, personal experience, financial considerations and available
equipment will influence what modality is used for the various pathologic conditions we meet in the field of
urogynecology. However some broad guidelines may be of use. It is now clear that pelvic floor abnormalities,
including all genitourinary pathologies, not only malignancies are best studied using sonography and
magnetic resonance imaging. Consequently the radiologists must now learn or reacquaint themselves with
the relevant anatomy and physiology in this expanding discipline.
Imaging of benign uterine pathology
Benign uterine lesions include malformations, pyometra, haematometra, lymphangiomas, vascular
abnormalities, adenomyosis, adenomyomas, polyps, leiomyomas. Most of these pathologies might give
similar symptoms such as pain and bleeding disturbances, symptoms that makes the woman to visit a
gynecologist. He has to make a correct diagnose even some of these maladies cannot easily be
discriminated between. Most gynecologists are prone to use transvaginal ultrasound as a routine
examination. Doppler technology discriminates lesions with specific patterns of blood circulation from others
with quite good accuracy. By combining vaginal ultrasound technique, hysteroscopy and laparoscopy most
uterine lesions can be correctly diagnosed. There are, however, some cases left over where there are
problems to decide the type and size of the lesion, whether it show invasive growth, what organs that may be
involved etc. Magnetic resonance imaging is believed to have superior sensitivity and specificity for the
diagnosis of uterine pathology compared with computed tomography and is therefore commonly used
preoperatively to come as close as possible to a correct diagnose (1).
Leiomyomas
They occur in up to 70% of women in reproductive age and are the most frequent indication for hysterectomy
in pre-menopausal women worldwide. In the last year in Slovenia, 650 hysterectomies were performed, 240
out of them per laparatomiam. 33% were done because of uterine fibromas. A recently described treatment
is uterine artery embolization. Ravina in 1995 published results from a pre-operative embolisation
programme originally aimed at reducing haemorrhage during hysterectomy and myomectomy.(2) It has
emerged as an effective minimal-invasive treatment alternative for women with symptomatic leiomyomata of
the uterus with promising short and midterm results. It is known that approximately one third of women with
uterine leiomyomas have symptoms that may eventually require medical or surgical intervention. As so, it
may become the initial treatment of choice for symptomatic uterine fibroids that cause menorrhagia, (severe
menstrual pain) dysmenorrhoea, dyspareunia, abdominal distention, pressure effects on adjacent structures
and urinary frequency, infertility and pregnancy loss. If patient demand for uterine artery embolization
increases and the procedure becomes more commonly performed, changes in work flow and reallocation of
resources will be required in order to meet the demand (3). The great advantage of this treatment is that in
the future it may be recommended unequivocally for those women desiring maintenance of fertility and future
pregnancies. It is also likely there will be substantial cost savings with the increased use of uterine artery
embolisation instead of surgery. It is well tolerated and has a shorter recovery time compared with surgical
alternatives in most patients.
At the Department of Radiology University Medical Center in Ljubljana, since the year 2004 we have done 27
uterine embolisation procedures. 16 of them were performed due to uterine fibroids. Three times we have
done it in order to stop bleeding in patients with cervical cancer stage III-IV. Once we successfully stopped
bleeding in a case with endometrial cancer with contraindication for surgery. Once, bilateral uterine artery
baloon obliteration saved the life of a 19 year old female patient who suffered serious damage of her pelvis
after falling under a truck in a car accident. After reconstruction of her bony pelvis she had a sutured vagina
and urethra which were cut off from her urinary bladder. In cases with uterine fibroids clinical results show
that in more than 90 % of cases there is improvement of abnormal bleeding and a reduction of uterine
volume in up to 50% (4).
59

Postmenopausal bleeding
The basic, noninvasive and cheap method to evaluate the aetiology of postmenopausal bleeding is
transvaginal ultrasound. It is used to evaluate the thickness, texture and morphology of the endometrium.
The normal postmenopausal uterus has a thin homogeneous endometrial basal bilayer of < 5 mm. This is
normal and no biopsy is needed (5). Any patient with postmenopausal bleeding and endometrial bilayer
thickness >5mm, heterogeneity, or focal mass/thickening should get further assessment with saline infusion
hysterosonography, biopsy, or hysteroscopy. If the thickening is diffuse on saline infusion
hysterosonography, then biopsy may be performed. If there is focal thickening, then hysteroscopy is
preferred to localize polyps, focal hyperplasia, or cancer in order to guide tissue sampling (6). 85-90% of
women presenting with postmenopausal bleeding have benign conditions such as atrophy, hyperplasia, or
anatomic reasons such as polyps or fibroids.
Endometrial carcinoma
10-15% of women with postmenopausal bleeding have endometrial carcinoma. It is the most common
gynecologic malignancy, and the fourth most common female cancer behind breast, lung and colorectal
cancers. Most patients present with vaginal bleeding at an early and treatable stage. Preoperative staging of
endometrial carcinoma is important for treatment planning and prognosis. Accurate pretreatment assessment
of endometrial cancer at imaging can potentially optimize surgical and non surgical treatment. Imaging
findings are diffuse thickening of the endometrium, heterogeneous texture, focal irregularity, distortion of the
myometrial interface, significant endometrial fluid, and poor distensibility of the endometrial canal on saline
infusion hysterosonography. Diagnosis requires tissue sampling. Hysteroscopy is the gold standard for
guided biopsy of endoluminal masses (7).
Cervical cancer
Is the most common cancer in females of undeveloped countries. The incidence of cervical cancer in
Slovenia in the year 2000 was 19,6/100000 women and is increasing till now. It presents 4% of all female
malignancies. As a result of increased understanding of the natural history of cervical cancer, the surgical
approach to early invasive cervical carcinoma has been changing gradually from a radical approach to a
conservative procedure resulting in decreased mortality and morbidity, as well as better quality of life. A
proper preoperative consideration involves beside history and careful physical examination a valuable
morphologic assessment of changes of pelvic anatomy. MR imaging is of great value in decision making for
surgery or radiation therapy in the treatment of cervical cancer. It has an excellent accuracy for the
assessment of tumor size, parametrial invasion and presence of lymph nodes enlargement. Staging of
cervical cancer larger than 1,5 cm using MRI of the pelvis has been shown to be cost-effective and more
accurate than with computed tomography, particularly in the diagnosis of parametrial invasion (8).
Endometriosis
The prevalence varies in different groups of women, rising from 2,5 to 5,9 % in fertile premenopausal
women to 20-50 % in infertile women, overall figures ranging from 6 to 44 %.
One of the difficulties in determining the prevalence of this disease in the general population is that
laparascopy or surgery is needed to make a definitive diagnosis. Evidence suggests that the current
treatment pathway for endometriosis typically involves a diagnostic delay of up to 7 years for women
suffering from a debilitating and painful disease, and that then patients no longer trust the advice they
receive or the healthcare professional giving it (9).
The extent of endometriosis varies from very small unseen endometrial glandular tissue growth to large
endometriomas the size of fetal head. Ultrasound is still the golden standard in everyday clinical practise for
the detection of cystic adnexal formations. MR imaging has a potential to detect lesions larger than one cm
in diameter with a sensitivity of more than 80 %,
but has low sensitivity for diagnosing implants and adhesions
Pelvic floor dysfunction and female stress urinary incontinence
Expanding clinical interest in urogynecology results in increasing imaging needs and better imaging
techniques result in increased utilization. The knowledge of the anatomy of pelvic floor organs has improved.
What was an unfortunately poorly understood and underserved area of female anatomy is now center of
attention of the new subspecialty of urogynecology. Besides traditional there are numerous new imaging
60

modalities for evaluation of pelvic pathology. Intravenous urography is still useful to rule out upper urinary
tract pathology. Voiding cystourethrography is a simple and low cost procedure that may be helpful in initially
studying complex pelvic floor anomalities, congenital anomalies, large and/or wide necked diverticula,
adjacent masses, fistulae and the results of urethral surgery. Vaginography can be helpful in situations when
an urethrovaginal fistula is difficult to demonstrate on voiding cystourethrography or a double balloon
urethrogram. Double balloon retrograde urethrography allows better visualization of diverticula, fistulae and
other abnormalities. Ultrasound measurement of postmictional residual urine volume is today routine clinical
necesity. Stress urinary incontinence as a consequence of bladder neck hypermobility is morphologically
evaluated by ultrasound or MRI. Perineal ultrasound diagnostic echoscopy has several significant
advantages over radiologic methods which have been in common use till now. Perineal ultrasound is a
simple, non-invasive, cheap, safe and reproducible diagnostic method for evaluation of bladder neck
hypermobility. It is recomended to be used as a routine clinical preoperative assessment of female urinary
incontinence. Patients with stress urinary incontinence have a statistically significant greater downward
displacement of the bladder neck during stress as continent ones. Doppler techniques permit assessment of
vascularity, 3 D modality better space orientation; CT and MRI better preoperative visualisation of structures
visible before only to anatomists and pathologists. Dynamic MRI is used for grading pelvic floor relaxation
(10).
Investigation of female infertility
The oldest method of evaluating the uterine cavity and tubal passage is hysterosalpingography (HSG).
Comparing it with hysterosalpingosonography the later has the advantage because the investigation could be
performed by the gynecologyst and gives immediate results in contrast with HSG which is done by the
radiologist. Hysterosalpingosonography includes like HSG both evaluation of the uterine cavity, tubal
passage however the difference being that transvaginal ultrasound is used instead of X-ray. The uterine
cavity is evaluated with instillation of saline by a cervical catheter while the tubes are reproduced white by a
positive contrast solution containing galactose. MR imaging is suitable for evaluation of uterine factors, but is
not able to assess tubal patency and peri-tubular adhesions (11).
Female genital anomalies
Transabdominal and transperineal ultrasound are of paramount value in diagnosing female genital
anomalies. The use of sterile saline as a contrast agent to outline the vagina, rectum or urogenital sinus may
be very helpful in the evaluation of the pediatric patient with complex congenital anomalies of the
genitourinary tract. Congenital anomalies of the genital tract result from Műllerian duct anomalies and/or
abnormalities of the urogenital sinus or cloaca. Failure of fusion of the Műllerian duct results in a wide variety
of fusion abnormalities of the uterus, cervix and vagina. Műllerian duct abnormalities may occur alone or in
association with urogenital sinus or cloacal malformations. Persistence of the cloaca is believed to be caused
by an abnormal development of the dorsal part of the cloaca and the urorectal septum. Urogenital sinus
malformations occur after the cloaca has been organized into urogenital sinus and the anus. Due to the close
embryologic relationship between the urinary and the genital tract malformations involving both organ
systems are very common (12).
Fetal imaging modalities
Ultrasound is the imaging modality of choice for prenatal screening and assessment of fetal deformities. It
has long been accepted that an alternative imaging tool is needed in cases where sonographic diagnosis is
difficult. MRI, which like ultrasound, lack ionizing radiation is especially appealing in the pregnant patient but
until recently has been limited by motion artefact. With the development of ultrafast MR imaging technique,
such as single-shot fast spin-echo, high quality fetal images are possible without the need for sedation. At
present, there is no conclusive evidence that exposure to clinical MRI conditions is harmful to the fetus.
Anyhow more work is needed including cost analysis, before the role of MRI in antenatal diagnosis is clearly
defined (13).
Surgical intraoperative complications
Iatrogenic ureteral injuries are among the most serious complications of gynecological operations. Ureteral
injuries may complicate 0,5 to 1 % of all pelvic operations and are usually complicated by a delay in
diagnosis (14). Ureteral injuries complicate postooperative course, compromise final results, require
secondary surgical treatment and could jeopardize patient life. Although the risk for ureteral lesion is
61

increased in malignancy, after previous pelvic operations or radiotherapy, in the presence of endometriosis
and pelvic inflammatory disease, the majority of the injuries occur during rutine hysterectomy for benign
conditions, usually described as »uncomplicated«. Pelvic surgeons, particularly gynecologists should be
comfortable with the ureteral course and familiar with the sites of frequent injuries during pelvic surgery. The
gynecologist must be familiar with safe techniques for routine identification of the ureter. In addition all
gynecologists should be familiar with techniques to identify urinary tract injuries and be able to perform
simple temporizing procedures and repairs while complex reconstruction procedures usually are left to the
urologist. Contrast X ray morphologic diagnostic investigations are crucial for the exact diagnosis.
Intravenous urography and retrograde ureteropyelography are of special value(15,16).
Conclusion
Gynecologists are aware of the important need for an evidence-based diagnostic pathway for the special
pathology in this field. In the future clinicians will search for simple, safe, time-effective and reproducible
imaging modalities which will avoid multiple separate diagnostic procedures, which in the sum are obviously
costly, time-consuming and sometimes even invasive, what is in gynecological aspect of special importance.
Precise pretreatment diagnostic evaluation respecting intimacy and patient integrity are our future
expectations.
References
1. Hamm B, Kubik-Huch RA, Fleige B. MR imaging and CT of the female pelvis:
radiologic-pathologic correlation. Eur Radiol. 1999; 9(1):3-15.
2. Cramer SF, Patel A. The frequency of uterine leiomyomas. American Journal
of Clinical Pathology 1990; 94: 435-438.
3. Cowan NC, Tattersall DJ, Holt SJ, Dobson D, Rees MC, Barlow DH. Uterine artery embolization for leiomyomas and adenomyosis:
Mid-term results from a prospective clinical trial. Radiology (P) 2001; 221:30.
4. Watson GMT, Walker WJ. Uterine artery embolisation for treatment of symptomatic fibroids in 114 women: reduction in size of the
fibroids and women's view of the success of the treatment. British J of Obstetrics and Gynecology 2002; 189: 129-35.
5. Ferazzi E, Torri V, Trio D, et al. Sonographic endometrial thickness: a useful test to predict atrophy in patients with postmenopausal
bleeding – an Italian multicenter study. Ultrasound Obstet Gynecol 1996; 7: 315-321.
6. Goldstein RB, Bree RL, Benson CB, et al. Evaluation of the woman with postmenopausal bleeding: Society of Radiologists in
Ultrasound sponsored consensus conference statement. J Ultrasound Med. 2001; 20: 1025-1036.
7. Levine DA, Hoskin WJ. Update in the management of endometrial cancer. Cancer J 2002; 8, Suppl: 1: 531-40.
8. Monsonego J, Franco E, editors. Cervical cancer conrol. General statements and Guidelines. Eurogin-WHO International Joint
meeting. Unesco Paris, March 24-27,1997.
9. Thomas EJ. The clinician's view of endometriosis. International J of Gynecology and Obstetrics. 1999, Vol 64, Suppl 1: S1-S3.
10. Schaer GN, Koechli OR, Schuessler B, Haller U. Perineal ultrasound for evaluating the bladder neck in urinary incontinence. Obstet
Gynecol 1995; 85: 220-224.
11. Schwartz LB, Panageas E, Lange R, Rizzo J, Comite F, Mc Carthy S. Female pelvis: Impact of MR imaging on treatment decision and
net cost analysis. Radiology 2000; 214: 39-46.
12. Gassner I, Geley T. Ultrasound of female genital anomalies. Eur Radiol. 2004; 14: L107-L122.
13. Garden AS. Fetal and fetal organ volume estimation with magnetic resonance imaging. Am Journal of Obstetrics and Gynecology
1996; 175: 442-448.
14. Higgins CC. Ureteral injuries during surgery. Jama 1976, 199: 118-124.
15. Bright TC, Peters PC. Ureteral injuries secondary to operative procedures. Urology 1977; 9: 22.
16. Witters C, Cornelissen M, Vereecken R. Iatrogenic ureteral injury: aggressive or Conservative treatment. Am J Obstet Gynecol, 1986;
155: 582-4.
PREOPERATIVE ASSESSMENT OF BENIGN DISEASES OF THE FEMALE
PELVIS: ENDOMETRIOSIS
PD, Dr. med Karen Kinkel,
Clinique des Grangettes, Chêne-Bougeries, Geneva, Switzerland
Endometriosis corresponds to ectopic growth of functional endometrial glands associated with stromal tissue.
Pain is the cardinal symptom of endometriosis. Various types of pain are associated with the disease;
dysmenorrhoea, deep dyspareunia, and pelvic pain unrelated to intercourse or menstruation. Infertility is
another commonly associated complaint. The diagnosis of endometriosis still presents several problems
resulting from similarities in clinical symptoms to other benign or malignant gyneaecological diseases.
62

Imaging techniques currently used to diagnose endometriosis are sonography, computerized tomography
(CT) and magnetic resonance imaging (MRI). Sonographic examination of the pelvis is the initial method of
choice to identify and characterize adnexal cystic structures. Medical or surgical treatment options depend on
the patient’s age and pregnancy desire, the importance and recurrence of symptoms, the extent of disease
and history of prior treatment.
Endometriosis of the pelvis includes a variety of different anatomic location and degrees of disease such as
superficial or peritoneal endometriosis, endometriomas or endometriosis of the ovary and deep peritoneal
endometriosis divided into anterior and posterior endometriosis [1]. Ovarian endometriosis can be detected
by ultrasound, using a combined transabdominal and transvaginal approach. Characteristic sonographic
features of endometriomas are diffuse, low-level internal echoes, multilocularity and hyperechoic foci in the
wall [2]. Differential diagnoses include corpus luteum, teratoma or dermoid cyst, cystadenoma, ovarian
fibroma, tubo-ovarian abscess and carcinoma. Repeated ultrasound is highly recommended for unilocular
cysts with low-level internal echoes to differentiate functional corpus luteum from neoplastic ovarian cysts
such as endometriomas. At magnetic resonance imaging (MRI) endometriomas appear as homogeneously
high-signal intensity cysts at T1-weighted fat suppressed images and as low-signal intensity cysts with focal
high-signal intensity areas at T2-weighted images[3]. Gradual variation of signal intensity at T2-weighted
images has been described as “shading” and is due to chronic bleeding with accumulation of high
concentration of iron and protein in endometriomas [3]. Frequently the cyst is filled with blood of different
ages. However the purpose of MRI is not detection of endometriomas easily diagnosed at ultrasound but the
identification of peritoneal and subperitoneal disease.
Superficial endometriosis of peritoneal implants is hardly detected by any imaging method due to their size
smaller than 5mm. MRI using fat suppressed sequences my detect 75% of peritoneal implants larger than
5mm demonstrating signal intensities similar to “microendometriomas” according to the age of hemorrhage.
Subsequent adhesion formation is identified at MRI only in patients with severe adhesion. Angulation of
bowel structures or hypointense lines in the surrounding fat converging in spicules towards the fixed organ,
are suggestive of adhesions. Hematosalpinx can be identified at both, ultrasound and MR imaging as tubular
structures with interrupted septa and signal intensity of blood. However tubal obstruction without tubal
dilatation will not be identified with these imaging techniques without the use of intrauterine fluid currently
under investigation. Therefore hysterosalpingography remains the first imaging technique in patients with
infertility.
The assessment of the pouch of Douglas can be impaired during diagnostic laparoscopy for infertility by
severe adhesions covering the posterior pelvis. The main benefit of MRI in patients with pelvic pain is the
diagnosis of extra-ovarian endometriosis which can be located anteriorly between the bladder and the uterus,
or posteriorly at the level of the uterosacral ligaments, the torus uterinum (posterior part of the uterine
isthmus between the insertions of both uterosacral ligaments), the posterior vaginal fornix or the rectosigmoid
[4, 5]. Endometriosis of the bladder corresponds to nodular wall thickening, easily identified at ultrasound and
mimicking bladder cancer. At MRI, bladder endometriosis associates T2 hypointense posterior wall
thickening and T1 and T2 hyperintense spots. Extension to the ureters is crucial before planning partial
cystectomy. Axial T2-weighted 3mm sections and MR urography are superior to intravenous pyolography to
diagnose internal or external endometriosis of the ureter. Symptoms of posterior endometriosis depend on
lesion location and include dyspareunia, dysmenorrhea and painful defecation. Endometriosis of uterosacral
ligaments include their hypointense thickening above 7mm, often associated with nodularity. T2 hypointense
nodules with decreased contrast uptake after intravenous administration of Gadolinium compared to normal
surrounding structures. Endometriosis of the bowel can be located at the rectosigmoid colon, the appendix,
the cecum and the distal ileum. The lesion invades the serosa, subserosa and muscularis propria reacting
with hypertrophia and fibrosis. Due to the normal appearance of the mucosa in most patients with bowel
endometriosis diagnosis by colonoscopy is often false negative. Diagnostic criteria of rectal invasion at MRI
included colorectal wall thickening with anterior triangular attraction of the rectum towards the torus uterinum
or thickening of the lower surface of the sigmoid [5]. Evaluation of the distance of the lower border of the
lesion up to the junction of the pelvic and perineal rectum was possible in all patients with rectal involvement.
This information is important for surgical decision making.
63

MRI represents the optimal method to diagnose and define the extent of all lesion locations, particularly at
the torus uterinum, the utero-sacral ligaments, the upper vagina or the bowel. Surgical management of deep
endometriosis is a complex and high risk procedure. A satisfactory preoperative work-up is necessary to
precise exactly the locations of all the deep lesions. Because of the difficulties of these surgical procedures, it
is strongly recommended to refer patients with suspected or diagnosed deep endometriosis to specific
centers with a multidisciplinary approach. In patients who do not undergo surgery, MRI of the pelvis can be
used to monitor response to medical treatment.
References
1. Chapron C, Fauconnier A, Vieira M, Barakat H, Dousset B, Pansini V, Vacher-Lavenu MC, Dubuisson JB. Anatomical distribution of
deeply infiltrating endometriosis: surgical implications and proposition for a classification. Hum Reprod 2003, 18: 157-161.
2. Patel MD, Feldstein VA, Chen DC, Lipson SD, Filly RA. Endometriomas: diagnostic performance of US. Radiology 1999, 210: 739-
745.
3. Togashi K, Nishimura K, Kimura I, Tsuda Y, Yamashita K, Shibata T, Nakano Y, Konishi J, Konishi I, Mori T. Endometrial cysts:
diagnosis with MR imaging. Radiology 1991, 180: 73-78.
4. Kinkel K, Chapron C, Balleyguier C, Fritel X, Dubuisson JB, Moreau JF. Magnetic resonance imaging characteristics of deep
endometriosis. Hum Reprod 1999, 14: 1080-1086.
5. Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN. Deep Pelvic Endometriosis: MR Imaging for Diagnosis and
Prediction of Extension of Disease. Radiology 2004, 232: 379-389 Epub 2004 Jun 2017.
PREOPERATIVE ASSESSMENT OF BENIGN DISEASES OF THE FEMALE
PELVIS: ADNEXAL DISEASES
Izumi Imaoka, MD, PhD.
Department of Radiology, Tenri Hospital, Japan
Transvaginal ultrasonography (TVS) has been foremost modality for the detection and characterization of
adnexal masses. Computed tomography (CT) or magnetic resonance imaging (MRI) can be considered
when the sonographic findings are indeterminate. MRI is especially capable of characterizing adnexal
masses as hemorrhagic, fatty, cystic, or solid.
This presentation addresses CT and MR findings of benign adnexal diseases as a practical preoperative
assessment.
1. Adnexal masses vs. non-adnexal masses
Differential diagnosis for pelvic masses includes adnexal and non-adnexal masses. First, uterine subserosal
leiomyomas can mimic solid adnexal tumor (i.e., fibrothecoma). Splaying of the uterine myometrium indicate
uterine leiomyomas. MR imaging is appreciated to diagnose subserosal leiomyomas by demonstrating
vascular signal voids between the uterus and the mass (flow void sign) (1). Next, the mass arisen from nonreproductive
system is another consideration. Diseases of peritoneal origin, retroperitoneal origin, and
gastrointestinal origin can be misinterpreted as gynecologic masses. CT and MR findings of displacement of
ureter and iliac vessels (2), effacement of pelvic wall (2), tracking of tumor vessels and ovarian veins (3) are
helpful to differentiate extragonadal pelvic masses from adnexal diseases.
2. Neoplasm vs. non-neoplasm
Some of the non-neoplastic conditions are required observation or medication rather than operation.
Solitary follicle cysts and corpus lutem cysts, so called ‘functional cysts’, are common in women of
reproductive age. They usually range from 3 to 8 cm in diameter (4) and almost always regress within two
months. Therefore, cystic and unilocular adnexal masses less than 4-5cm in their dimension may be
observed with repeated sonography (5). They are well circumscribed cystic masses of near water density on
CT. MR demonstrates cystic masses of low signal intensity on T1-weighted images and high signal intensity
on T2-weighted images when they are uncomplicated.
Patients with tubo-ovarian abscess (TOA) present an adnexal mass. The diagnosis of pelvic inflammatory
disease (PID) and TOA is usually based on clinical findings. MR imaging also can be helpful for the
assessment of PID, by showing TOA, dilated fluid-filled tubes, and free pelvic fluid (6). Contrast enhanced
CT has advantages to assess PID extended to perihepatitis (Fitz-Hugh-Curtis syndrome: FHCS). Hepatic
and splenic capsular enhancement was reported as characteristic findings of FHCS (7).
64

Peritoneal inclusion cysts are caused by accumulation of ovarian fluid associated with peritoneal adhesion.
They may be misinterpreted as complex cystic adnexal masses, however, accurate preoperative diagnosis
allows conservative therapy rather than surgical resection. The entrapped ovary inside the cyst can be
shown on CT and MR imaging (8).
3. Benign vs. malignant
Appropriate preoperative assessment may helps gynecologist for preparing ystectomy and/or laparoscopic
management rather than oophorectomy or salpingi-ophorectomy, or transabdominal procedure in patients
with benign adnexal masses.
Mature cystic teratoma (dermoid cyst) is the most common ovarian tumor. The cyst is lined with keratinized
squamous epithelium and skin appendages. Therefore sebaceous contents are quite common within mature
cystic teratomas. Fat attenuation within the cyst is a diagnostic finding on CT. MR imaging demonstrates
the fat material as high signal intensity component parallelling that of subcutaneous fat tissue on T1- and fast
spin echo T2-weighted images. A selective chemical fat-suppression technique improves diagnostic
confidence (9, 10).
Endometriosis is characterized as the presence of tissue resembling endometrium outside the uterus.
Endometriotic cysts usually have thick, fibrotic wall with chocolate-colored hemorrhagic material. CT findings
are sometimes nonspecific ovarian masses. Methemoglobin in the aged cyclic hemorrhage causes T1-
shortening, therefore, (a) adnexal cysts of high signal intensity on both T1- and T2-weighted images or (b)
high signal intensity on T1-weighted images and low signal intensity on T2-weighted images, are diagnostic
findngis on MR imagings (11). The details will be presented by Dr. Kinkel in 'Endometriosis' session.
Finally, one of the major goals of the evaluation of adnexal diseases is to exclude a malignancy. The use of
intravenous contrast is essential to differentiate malignant from benign ovarian tumors. CT features of
ovarian malignancy include a cystic mass with thick internal septations and solid mural components, a cystic
and solid mass, and a lobulated/ papillary solid mass. The primary MR criteria are (a) solid mass or large
solid component, (b) wall thickness>3mm, (c) septal thickness>3mm and/or vegetations or nodularity, and (d)
necrosis (12, 13). Completely cystic and unilocular masses suggest benigncy, including functional cysts,
paraovarian cysts, and serous cystadenomas. Cystic and multilocular masses without any solid components
or vegetations/ nodularity include mucinous cystadenomas. Solid ovarian masses include various
pathologies. Of these, fibrothecomas are the most common solid benign tumors of the ovary.
Fibrothecomas and Brenner tumors can be diagnosed when solid masses show low signal intensity on T2-
weighted images because of extensive fibrous tissue and calcification (14, 15).
References
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
Magn Reson Imaging 1998; 8: 427-431.
2. Foshager MC, Hood LL, Walsh JW. Masses simulating gynecologic diseases at CT and MR imaging. Radiographics 1996; 16: 1085-
1099.
3. Saksouk FA, Jhonson SC. Recognition of the ovaries and ovarian origin of pelvic masses with CT. Radiographics 2004; 24: S133-
S146.
4. Clement PB. Nonneoplastic lesions of the ovary. In: Blaustein’s Pathology of the female genital tract, 5th ed, Kurman RJ ed. Springer,
New York, 2002, 675-727.
5. Fleischer AC. Sonographic evaluation of adnexal masses with transabdominal and Transvaginal sonography. In: Fleischer AC, et al
(eds) Clinical gynecologic imaging. Philadelphia: Lippincott-Raven Publishers, 1997; 48-86.
6. Tukeva TA, Aronen HJ, Karjalainen PT, Molander P, Paavonen T, Paavonen J. MR imaging in pelvic inflammatory disease:
comparison with laparoscopy and US. Radiology 1999; 210: 209-216.
7. Nishie A, Yoshimitus K, Irie H, et al. Fitz-Hugh-Curtis syndrome. Radiologic manifestation. Comput Assist Tomogr 2003; 27: 786-791.
8. Jain KA. Imaging of peritoneal inclusion cyst. Am J Roentgenol 2000; 174: 1559-1563.
9. Stevens SK, Hricak H, Campos Z. Teratomas versus cystic hemorrhagic adnexal lesions: differentiation with proton-selective fatsaturation
MR imaging. Radiology 1993; 186: 481-488.
10. Imaoka I, Sugimura K, Okizuka H, Iwanari O, Kitao M, Ishida T. Ovarian cystic teratomas: value of chemical fat saturation magnetic
resonance imaging. Br J Radiol 1993; 66: 994-997.
11. Togashi K, Nishimura K, Kimura I, et al. Endometrial cysts: diagnosis with MR imaging. Radiology 1991; 180: 73-78.
12. Stevens SK, Hricak H, Stern JL. Ovarian lesions: detection and characterization with gadolinium-enhanced MR imaging at 1.5 T.
Radiology 1991; 181: 481-488.
13. Hricak H, Chen M, Coakley FV, et al. Complex adnexal masses: detection and characterization with MR imaging- multivariate
analysis. Radiology 2000, 214: 39-46.
14. Troiano RN, Lazzarini KM, Scoutt LM, Lange RC, Flynn SD, McCarthy S. Fibroma and fibrothecoma of the ovary- MR imaging
findings. Radiology 1997;204:795-798.
15. Outwater EK, Siegelman ES, Kim B, Chiowanich P, Blasbalg R, Kilger A. Ovarian Brenner tumors: MR imaging characteristics. Magn
Reson Imaging 1998; 16: 1147-1153.
65

CLINICAL ASPECTS OF URINARY TRACT INFECTIONS
Andrej Bren
Department of Nephrology, University Medical Center, Ljubljana
Acute urinary tract infections (UTI) are divided into lower tract infections (urethritis and cystitis) and upper
tract infections (acute pyelonephritis, prostatitis, and intrarenal and perinephric abscesses). In most cases,
growth of >10 5 organisms per milliliter from a properly collected midstream “clean-catch” urine sample
indicates infection. Chronic pyelonephritis refers to chronic interstitial nephritis believed to result from
bacterial infections of the kidney. UTI are subdivided into catheter-associated (or nocosomial) infections and
non-catheter-associated (or community acquired) infections. Infections in either category may be
symptomatic or asymptomatic. The vast majority of acute symptomatic community-acquired UTIs involve
young women.
The most common microorganisms that infect urinary tract are gram-negative bacilli. Escherichia coli cause
80% of acute infections in patients without catheters, urologic abnormalities, or calculi. Proteus, Klebsiella
and Enterobacter account for smaller proportion of uncomplicated infections. These organisms, plus Serratia
an Pseudomonas are important in recurrent infections and infections associated with urologic manipulation,
calculi, or obstruction. They play the major role in nocosomial, catheter-associated infections. In the vast
majority of UTIs, bacteria gain access to the bladder via urethra. Ascent of bacteria from the bladder may
follow and is probably the pathway for most renal parenchymal infections. The female urethra appears to be
particularly prone to colonization with colonic gram-negative bacilli, because of its proximity to the anus.
Sexual intercourse causes introduction of bacteria into the bladder and is temporally associated with the
onset of cystitis. In pregnancy 20-30% of women with untreated asymptomatic bacteriuria subsequently
develop pyelonephritis. Any obstruction of the urinary tract and impediment to the free flow of urine (tumor,
stricture, stone, or prostatic hypertrophy)-results in hydronephrosis and a greatly increased frequency of UTI.
Neurogenic bladder dysfunction (spinal cord injury, tabes dorsalis, multiple sclerosis, diabetes, etc) may be
associated with UTI. Vesicoureteral reflux is common among children with anatomic abnormalities of the
urinary tract as well as among children with anatomically normal but infected urinary tract.
Patients with cystitis usually report dysuria, frequency, urgency, and suprapubic pain. Symptoms of acute
pyelonephritis generally develop rapidly over a few hours or a day and include fever, shaking, chills, nausea,
vomiting, and diarrhea. In some patients, signs and symptoms of gram-negative sepsis predominate. About
30% of women with acute dysuria, frequency, and pyuria have midstream urine cultures that show either no
growth or insignificant bacterial growth. A distinction should be made between infection with sexually
transmitted p0athogen (CV. Trachomatis, N. gonorrhoeae, or herpes simplex virus, and those with low-count
E. coli or staphylococcal infection of the urethra or bladder. Bacteriuria develops in at least 10 -15% of
hospitalized patients with indwelling urethral catheters. The risk of infections is 3-5% per day of
catheterization. Clinically, most catheter-associated infections cause minimal symptoms and no fever and
often resolve after removal of the catheter. Gram-negative bacteriemia occurs in 1-2% of cases with
catheter-associated infections. The catheterized urinary tract has repeatedly been demonstrated to be the
most common source of gram-negative bacteremia in hospitalized patients, generally accounting for 30% of
cases.
Diagnostic testing includes determination of the number and type of bacteria in the urine. Pyuria is
demonstrated in nearly all acute bacterial UTIs, and its absence calls the diagnosis into question. Elevate
level of C-reactive protein often accompanies acute pyelonephritis.
Except in acute uncomplicated cystitis in women, a quantitative urine culture should be performed to confirm
infection. Factors predisposing infections should be corrected. Relief of clinical symptoms does not always
indicate bacteriological cure. Each course of treatment should be classified after its completion as a failure or
a cure. Lower uncomplicated infections in general respond to short course of therapy, while upper tract
infections require longer treatment.
Very few women with recurrent UTIs have correctable lesions discovered at cystoscopy or upon intravenous
pyelography, and these procedures should not be undertaken routinely in such cases. Urologic evaluation
should be performed in selected instances- namely in women with relapsing infections, a history of childhood
infections, stones or painless hematuria, or recurrent pyelonephritis. Most males with UTI should be
considered to have complicated infection and should be evaluated urologicaly. Any patient presenting with
acute infection and signs or symptoms suggestive of an obstruction or stones should undergo prompt
urologic evaluation, generally by means of ultrasound.
66

In patients with uncomplicated cystitis or pyelonephritis, treatment ordinarily results in complete resolution of
symptoms. Acute uncomplicated pyelonephritis in adults rarely progresses to renal function impairment and
chronic renal disease. Repeat symptomatic UTIs with obstructive uropathy, neurogenic bladder, structural
renal disease, or diabetes progress to chronic renal disease with unusual frequency.
Women with frequent symptomatic UTIs are candidates for long-term administration of low-dose antibiotics
directed at preventing recurrences.
DIAGNOSTIC IMAGING OF PYOGENIC INFECTIONS IN THE URINARY TRACT
Takehiko Gokan
Radiology, Showa University School of Medicine, Tokyo, JAPAN
Acute urinary tract infections usually are diagnosed and treated on the basis of clinical symptoms and
laboratory findings. With appropriate antibiotics, symptoms generally abate within 48 to 72 hours, and
radiological evaluation is not necessary. The use of diagnostic imaging is usually reserved for patients whose
clinical diagnosis is unclear, patients who fails to respond to conventional medical treatment, diabetic
patients, and other immunocompromised patients.
In chronic urinary infection, diagnosis may be delayed because of the non-specific presentation and rarity of
these processes. With the ability of newer imaging method, such as ultrasonography and CT, as early
diagnosis of s specific chronic infection may be made. However, this requires that the radiologist be aware of
the specific radiological findings of the various chronic infections.
Acute Pelonephritis
Acute pyelonephritis refers to infection of the kidney by haematogenous spread of organism or by ascending
spread of infection from the bladder. There are two legitimate but distinct definitions of acute bacterial
pyelonephritis. One is clinical definition that is based on clinical and laboratory findings . The other is the
pathologic definition that is based on a set of macroscopic and microscopic abnormalities. Some patients
whose kidneys fulfil the pathologic criteria for acute pyelonephritis lack clinical or laboratory evidence of
disease.
In most cases of acute pyelonephritis, the inflammatory process is reversible, but severe vasospasm and
inflammation may occasionally result in liquefactive necrosis and abscess formation.
Intravenous urography or ultrasound generally occasionally fails to show any abnormality in acute
pyelnephritis. Precontrast CT shows renal enlargement or focal swelling without abnormality of attenuation.
Postcontrast CT wedge-shaped or streaky zones of low attenuation extending from papilla to kidney capsule.
Zone of low attenuation on contrast-enhanced scans are almost caused by focal ischemia, obstructed tubles,
and interstitial inflammation. Clinically mild and uncomplicated acute pyelonephritis may show no abnormality
on CT.
Emphysematous Pyelonephritis
The presence of gas within the renal parenchyma has been referred to as emphysematous pyelonephritis,
which represents a severe life-threatening infection of the renal parenchyma with gas-forming bacteria.
Underlying poorly controlled diabetes mellitus is present in up to 90 % of patients and urinary collecting
system obstruction from pathologic conditions such as stone disease, urothelial neoplasm, or sloughed
papilla is also commonly present. Women are affected more often than men and the average age at
presentation is in the mid-50s. The clinical presentation includes features typical of a severe acute
pyelonephritis including fever and chills, flank or abdominal pain, and nausea and vomiting. Mortality rates
are high for medical therapy alone. E. coli is the causative bacterial source in approximately 70 % of cases.
Plain films of the abdomen and IVU have been reported ton suggest the presence of gas in 85% of cases.
However, the use of intravenous contrast is often contraindicated in these patients in part because of high
frequency of underlying renal dysfunction. Ultrasound has been used in the evaluation of these patients and
may show hyperechoic foci with posterior acoustic shadowing from gas within or surrounding the kidney.
67

However, ultrasound often fails to show the full extent of the disease and in some cases may miss the
relevant findings completely. CT scan is the imaging procedure of choice in evaluating the presence and
extent of disease in patients suspected of having emphysematous pyelonephritis. Wan et al divides
emphysematous pyelonephritis into two types and has prognostic significance. Type I is characterized by
parenchymal destruction with streaky or mottled gas collections but no significant fluid collection. Type II is
characterized by bubbly or loculated gas within the parenchyma or collecting system with associated renal or
perirenal fluid collections that are thought to represent a favourable immune response. Type I has a 69%
mortality rate versus 18% for type II, although transformation from type I to Type II has been observed
following conservative treatment.
Emphysematous Cystitis
Emphysematous cystitis represents a rare form of acute inflammation of bladder mucosa and underlying
musculature. Clinical symptoms of dysuria, increased urinary frequency, and hematuria are common. The
presence of pneumaturia is rare, although more specific, clinical findings. Underlying diabetes mellitus is
present in over half of reported cases, with women being affected twice as often as men.
CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. It is also
useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel
carcinoma or inflammatory disease.
Renal abscess
Renal abscess is a collection of purulent material confined to the renal parenchyma. Before the antimicrobial
era, 80% of renal abscess were attributed to haematogenous seeding by staphylococci. Since about 1970,
gram-negative organisms have been implicated in the majority of adults with renal abscess. Ascending
infection associated with tubular obstruction from prior infection or calculi appears to be the primary pathway
for the establishment of gram-negative abscess.
IVU or Ultrasonography may show a abscess but lack of sensitivity to show extent of infection adequately.
CT is currently the most accurate modality for detection and follow-up of renal abscess. An abscess usually
appears as a well-defined mass of low attenuation with a thick, irregular wall or pseudocapsule, which is
better imaged with contrast enhancement. Gas within a low-attenuating or cystic mass strongly suggests
abscess formation. Fascial and septal thickening and perinephric fat obliteration are usually present. A
perinephric abscess may result from rupture of a renal abscess into the perirenal space but most often
develops directly from acute pyelonephritis.
Pyonephrosis
The term pyonephrosis refers to an obstructed, infected collecting system with grossly purulent contents. Any
cause of chronic ureteral obstruction predisposes to pyonephrosis. Patients may present with signs and
symptoms of acute infection, or with low-grade fever, weight loss, and dull pain. However, as many as 15%
of patients have no symptoms and others have a more indolent, chronic presentation.
Ultrasonography has greatly aided the diagnosis, since the contents of dilated collecting system can be
shown even when function is nil. The classic US findings in pyonephrosis is the presence of echogenic
material in a dilated collecting system. By CT scan, the most frequently encountered findings is thickening of
the renal pelvic wall. Other findings include stranding of the perirenal fat and a striated nephrogram, findings
suggestive but not specific for renal infection is general. Although uncommon, in one series, air in the
collecting system was the most specific findings. Most authors stress the need for aspiration of the collecting
system in appropriate clinical setting.
Xanthogranulomatous Pyelonephritis
Xanthogranulomatous pyelonephritis is an uncommon complication of long-standing urinary tract obstruction
with a superimposed chronic infection, usually with P mirabilis or E coli. Most cases are unilateral and result
in a non-functioning, enlarged kidney associated with obstructive uropathy secondary to nephrolithiasis.
CT is probably the most useful radiological technique in evaluating patients with xanthogranulomatous
pyelonephritis. CT usually demonstrates a large, reniform mass with the renal pelvis tightly surrounding a
68

central calcification but without pelvic dilatation. Renal parenchyma is replaced by multiple water-density
masses representing dilated calyces and abscess cavities filled with varied amounts of pus and debris. On
enhanced CT, the walls of these cavities demonstrate a prominent blush owing to the abundant vascularity
within the granulation tissue. Xanthogranulomatous pyelonephritis is usually diffuse but may be focal or
segmental.
Chronic Pyelonephritis
Chronic pyelonephritis is a chronic interstitial nephritis caused by infection, although some of the damage
may be autoimmune mechanism. The bacteriology of the disorder is the same as for acute pyelonephritis,
and in fact most cases of chronic pyelonephritis are cases of scarring from prior infections.Chronic
pyelonephritis scarring most often results from lower urinary tract infestation and vesicoureteral reflux,
usually in childhood. Chronic pyelonephritis can occur in other clinical setting. The most common are in the
presence of calculi and chronic obstruction.
In Intravenous urography, the involved kidneys are usually small and atrophic. Focal coarse renal scarring
with clubbing of the underlying calyx is characteristic. Since the renal scarring and atrophy commonly affect
the renal poles, the renal parenchyma is especially thin in these areas. Ultrasonography may be used to
make the diagnosis, especially in children. Focal scars and blunted calices are recognized less readily with
ultrasonography than with urography. CT is helpful in identifying focal areas of compensatory hypertrophy
adjacent to the areas of renal scars; such hypertrophy may simulate a mass at excretory urography or renal
ultrasonography.
TUBERCULOSIS AND UNCOMMON INFECTIONS OF THE UROGENITAL
TRACT
Tarek A. El-Diasty, MD
Department of Radiology, Urology and Nephrology Center
Mansoura University, Mansoura – Egypt
Genitourinary Tuberculosis
Genitourinary tuberculosis is the most common manifestation of extrapulmonary tuberculosis.
Mycobacterium tuberculosis reaches the genitourinary tract as a secondary site following hematogenous
dissemination from the lung. The kidneys and possibly the prostate and seminal vesicles are often the
primary sites of genitourinary tuberculosis (1) . All other genital organs become involved by ascent or descent
of M tuberculosis. The testis may become involved by direct extension from an epididymal infection, but
hematogenous spread to the testicle is rarely seen (2) .
Renal tuberculosis:
Tuberculosis of the kidney results from hematogenous seeding of M tuberculosis in the glomerular and
peritubular capillary bed from a pulmonary site of primary infection (3) . Radiography may demonstrate
calcification within the renal parenchyma. The calcification may be amorphous, granular, curvilinear, or lobar
(putty kidney) (4,5) . Intraverous urography demonstrates a variety of findings depending on the extent of renal
involvement. The earliest urographic abnormality is a “moth-eaten” calyx due to erosion. This finding is
followed by papillary necrosis. Poor renal function, dilatation of the pelvicalyceal system due to a stricture of
the ureteropelvic junction, or destructive dilatation or localized hydrocalycosis related to an infundibular
stricture. Infundibular stenosis may lead to incomplete opacification of the calyx (phantom calyx) (6) . Cavitation
within the renal parenchyms may be detected as irregular pools of contrast material. Cicatricial contracture of
fibrotic parenchyma may lead to caliceal or renal pelvic traction. Calculi may be present within the renal
collecting system. End-stage fibrosis and subsequent obstructive uropathy produce autonephrectomy. At this
time, renal assessment is best achieved with US, CT or MR imaging (7-9) .
CT is helpful in identifying the manifestations of renal tuberculosis (e.g. calcification). Various patterns of
hydronephrosis may be seen at CT depending on the site of the stricture. Other findings include parenchymal
69

scarring and low attenuation parenchymal lesions. CT is also useful in depicting the extension of disease into
the extrarenal space (2,9) .
The radiologic differential diagnosis of renal tuberculosis includes acute focal bacterial nephritis,
xanthogranulomatous pyelonephritis, other causes of papillary necrosis and small benign or malignant
tumors (10) .
Ureteral tuberculosis:
Ureteral involvement is seen in 50% of patients with genitourinary tuberculosis (7) . Dilatation and a ragged
irregular appearance are the first signs of ureteral tuberculosis. In advanced disease, ureteral strictures,
ureteral shortening, ureteral filling defects, or ureteral wall calcifications may be seen (5,7) . CT may
demonstrate thickening of the ureteral wall and periureteral inflammatory changes.
Bladder tuberculosis:
Typically, tuberculous cystitis manifests as shrunken bladder with wall thickening (11) . Occasionally, filling
defects due to multiple granulomas may also be seen. In advanced disease, the bladder may be diminutive
and irregular (thimble bladder). Advanced bladder involvement may be complicated by vesicoureteral reflux
due to fibrosis involving the ureteral orifice. Calcification of the bladder is rarely seen (10) .
Calcified tuberculous cystitis must be differentiated from shistosomiasis, cystitis due to cyclophosphamide,
radiation induced changes, calcified bladder carcinoma and encrusted foreign material. Bladder tuberculoma
may mimic transitional cell carcinoma.
Male genital tuberculosis:
The most common findings of tuberculous prostatitis, on transrectal US, is hypoechogenic areas with an
irregular pattern in the peripheral zone of the prostate. Contrast-enhanced CT shows hypoattenuating
prostate lesions which represent foci of caseous necrosis and inflammation. Nontuberculous pyogenic
prostatic abscess have a similar CT appearance (7) . At MR imaging, a prostatic abscess demonstrates
peripheral enhancement. This finding helps differentiate an abscess from prostatic malignancy. In addition,
MR imaging shows diffuse, radiating, streaky areas of low signal intensity in the prostate (“Watermelon Skin”
sign) on T2-weighted images (12) .
Tuberculous involvement of seminal vesicles may lead to necrosis, calcification, caseation and
cavitation (13,14) . Tuberculous epididymo-orchitis usually manifests at US as focal or diffuse areas of
decreased echogenicity with epididymal involvement (15) .
Female genital tuberculosis:
Fallopian tubes are affected in 94% of women with genital tuberculosis. Salpingitis caused by hematogenous
dissemination is almost always bilateral. A tubo-ovarian abscess that extends through the peritoneum into
the extraperitoneal compartment suggest tuberculosis (1) . Other diagnostic criteria for female genital
tuberculosis include endometrial adhesions with deformity and obliteration of the endometrial cavity,
obstruction of the fallopian tubes with multiple areas of constriction, and calcified lymph nodes in the adrexal
region (7) . Advanced tuberculous endometritis may mimic sever uterine adhesions as seen in Asherman
syndrome (10) .
The clinical and radiologic features of genitourinary tuberculosis and other rare infection may mimic those of
many diseases. A high index of suspicion is required, particularly in high-risk populations. Although a positive
culture or histologic evidence is still required in many patients to yield a definitive diagnosis, recognition and
understanding of the spectrum of imaging features of genitourinary tuberculosis, which will be outlined in this
lecture, are crucial for diagnosis.
References
1. Engin G, Acunas B, Acunas G, Tunaci M. Imaging of extrapulmonary tuberculosis. Radiographics 2000; 20: 471-488.
2. Chung J, Kin M, Lee T, Yoo H, Lee J. Sonographic findings in tuberculous epidymitis and epididymo-orchitis. J Clin Ultrasound 1997;
25: 390-394.
3. Gibson M, Puckett M, Shelly M. Renal tuberculosis. Radiographics 2004; 24: 251-256.
70

4. Premkumar A, Lattimer J, Newhouse JH. CT and sonography of advanced urinary tract tuberculosis. Am J Roentgenol 1987; 148: 65-
69.
5. Wang L, Wong Y, Chen C. CT features of genitourinary tuberculosis. J Comput Assis Tomogr 1997; 21: 254-258.
6. Brennan R, Pollack H. Nonvisualized “Phantom” renal calyx: causes and radiological approach to diagnosis. Urol Radiol 1979; 1: 17-
23.
7. Leder R, Low VH. Tuberculosis of the abdomen. Radiol Clin North Am 1995; 33: 691-705.
8. Das K, Indudhara R, Vaidyanathan S. Sonographic features of genitourinary tuberculosis. AJR 1992; 158: 327-329.
9. Goldman S, Fishman E, Hartman D. Computed tomography of renal tuberculosis and its pathological correlates. J Comput Assist
Tomogr 1985; 9: 771-776.
10. Harisinghani M, McLoud T, Shepard A, Ko FR, Shroff M, Muller P. Tuberculosis from head to tow. Radiographics 2000; 20: 449-470.
11. Roylance J, Penry JB, Davis ER, et al. The radiology of tuberculosis of the urinary tract. Clin Radiol 1970; 21: 163-170.
12. Wang JH, Sheu MH, Lee RC. Tuberculosis of the prostate: MR appearance. J Comput Assist Tomogr 1997; 21: 639-640.
13. Premkumar A, Newhouse JH. Seminal vesicle tuberculosis: CT appearance. J Comput Assist Tomogr 1988; 12: 676-677.
14. Wang JH, Chang T. Tuberculosis of the prostate: CT appearance. J Comput Assist Tomogr 1991; 15: 269-270.
15. Heaton ND, Hogan B, Michell M, et al. Tuberculous epididymo-orchitis: clinical and ultrasound observations. Br J Urol 1989; 64: 305-
309.
CLINICAL EVALUATION OF ACUTE RENAL FAILURE
Rafael Ponikvar
Department of Nephrology, University Medical Center Ljubljana
Introduction
The kidney is remarkable among organs of the body in its ability to recover from almost complete loss of
function, and most acute renal failure is reversible, although with subclinical residual defects in tubule and
glomerular function. Acute renal failure occurring as an isolated clinical condition has favourable prognosis.
In the last decades the epidemiology of acute renal failure has changed and the majority of nowadays cases
occur in intensive care units, where acute renal failure is a part of multiorgan failure. Prognosis in such
patients is less favourable, with mortality rates ranging from 40-90%, in different series. The cause of death
in such patients is not renal failure itself, but failure of the other organs, as hemodialysis can provide survival
to end stage renal disease patients for more than 30 years.
Etiology and pathogenesis of acute renal failure
Acute renal failure is a clinical syndrome characterized by a rapid decline of glomerular filtration rate and
retention of nitrogen waste products such as urea and creatinine. Oliguria (urin output

Imaging in acute renal failure
Ultrasonography of the urinary system (kidneys and bladder) is the essential imaging procedure required in
the diagnostic evaluation of acute renal failure. It provides information on the presence and volume of urine
in bladder, the position and size of the kidneys, the quality and width of renal parenchyma, presence or
absence of hydronephrosis. Although some authors say that renal ultasonography is not necessarily required
in acute renal failure, arguing that the main task of ultrasonography is to exclude obstruction that is very rare
in the absence of clinical suspicion, our policy is that every patient with acute renal failure requires urgent
ultrasonography of the urinary system. Obstruction can occur in the absence of clinical suspicion and missing
that diagnosis has serious consequences. In addition, a significant number of patients has acute renal failure
superimposed on chronic renal failure or even end-stage renal failure that was clinically presented as acute
renal failure and ultrasonography is indispensable in clarifying such conditions and helping to plan
therapeutic strategy.
Doppler ultrasonography is nowadays frequently added to standard two-dimensional ultrasonography. It
provides information about presence or absence of blood flow in the kidneys and the resistance to arterial
blood flow (measured by the resistance index). A very high resistance index (> 1.0) with the reversion of
blood flow in the diastole is a characteristic sign of venous thrombosis/occlusion, a rare but important
condition. Doppler follow-up in such patients can help to assess the success of therapy.
Other imaging procedures are rarely required in patients with acute renal failure. Sometimes computerized
tomography and/or angiography in required in trauma patients or patients where ultrasonography did not
provide sufficient information.
Renal biopsy
Renal biopsy is the ultimate diagnostic procedure in glomerulonephritis, vasculitis and to much lesser extent
in acute renal failure and interstitial nephritis. It is mandatory when specific therapy depends on its result.
Treatment of acute renal failure
Treatment of acute renal failure consists of symptomatic and also more specific therapy when it is indicated.
In prerenal azotemia improvement of renal perfusion is essential in order to prevent acute tubular necrosis.
In tubular necrosis there is no specific therapy which could significantly influence the course and outcome.
There are few drugs which can be recommended like furosemid and diltiazem or verapamil. It is still very
important to maintain normal fluid, electrolyte and acid-base balance. When the latter goal cannot be
achieved by drugs and infusion therapy, dialysis should be instituted.
Application of radiocontrast agents, especially in patients with preexistent renal injury, may lead to acute
tubular necrosis due to renal vasoconstriction and due to toxicity on tubular cells. N-acetyl cistein failed to
prevent toxic effect of radiocontrast agent, while 0.9% saline solution had favourable effect in preventing
acute tubular necrosis when applied 12 hours before and 12 hours after the application of contrast agent in
the dose of 1ml/kgBW/hour.
Conclusion
Acute renal failure is unique in the ability of restoring a completely lost renal function. The most important
part of acute renal failure is prerenal azotemia which can be efficiently treated by improving hypoperfusion of
the kidneys. In intrinsic acute renal failure, symptomatic therapy with application of furosemid and
nondihidropiridin calcium channel blockers is the treatment which is usually introduced. In anuric patients,
dialysis treatment should be instituted.
Ultrasound and Doppler sonography are imaging procedures of choice in acute renal failure. Other imaging
procedures with the use of nephrotoxic radiocontrast agents should be used only in strict indications.
72

EMERGENCIES IN KIDNEY TRANSPLANTATION: CLINICAL EVALUATION
AND THE NEPHROLOGIST'S PERSPECTIVE
Marko Malovrh
Department of Nephrology, University Medical Centre Ljubljana, Slovenia
1. Renal artery thrombosis occurs in about 1% (1) of transplants, usually in small-calibre arteries.
Nephrectomy generally is indicated, especially if the thrombosis occurs in the perioperative period.
2. Arterial stenosis occurs in 1-12% of cases, it may occur within months or years following transplantation,
and it is associated with the abrupt onset of hypertension. It can be suspected based on findings on
Doppler ultrasound; confirmation generally requires angiography to confirm the presence of the stenosis
and exclude proximal vascular disease. Management of arterial stenosis has increasingly turned to
percutaneous techniques, including angioplasty and stent placement. Renal transplantation is the
treatment of choice for patients with chronic renal failure from most causes. This recommendation is
born of its success from several points of view. With recent 1-year graft survival rates approaching 90%
and average graft lifetimes in excess of 10 years, this procedure is a cost-effective alternative to dialysis.
Recent studies show that renal transplantation prolongs patient lifespan relative to dialysis.
Early or late complications associated with renal transplantation may occur. Perioperative complications
occur in 15-20% of renal transplants. Early postoperative complications include the following:
Delayed graft function (DGF) varies based on donor, recipient, and transplant characteristics. Some
rules are generally applicable. DGF is rare with living donor grafts, probably because of the short cold
ischemia time (CIT), i.e. the time between perfusion of the graft with ice-cold preservative solution and
reperfusion with blood in the recipient. For cadaver kidneys, CIT remains the best predictor of DGF.
While most DGF kidneys eventually function, they do have a somewhat diminished lifespan compared to
kidneys that function immediately.
Vascular-related and ureter-related complications are possible:
3. Venous thrombosis occurs in 0.5-4% of cases. Thrombosis of the main renal vein has been treated
successfully in rare instances with thrombolytic agents, although typically the graft has infarcted by the
time the thrombosis is detected. Graft infarction may occur with patent main arteries and veins;
nephrectomy generally is required. Graft thrombosis associated with sepsis carries a significant recipient
mortality rate. Prompt nephrectomy is indicated.
4. Peritransplant fluid collections: sonographic evaluation of renal transplant complications is often
successful because many of the potential peritransplant complications are associated with fluid
collections. The superficial nature of a typical renal transplant allows good resolution with relatively few
reverberation echoes. During the immediate postoperative transplant period, most fluid collections in and
around the bed of the transplant are haematomas or urinomas. A hyperacute haematoma often presents
as a hypoechoic fluid-filled mass near the surgical site. Hematomas may be stable in size but can
enlarge rapidly. The enlarging haematoma may compress the kidney, resulting in a reduction of urine
output. Later, a haematoma becomes complex with both hypoechoic and echoic areas.
5. Ureteral obstruction is the most common urinary tract problem associated with transplantation. The
reported incidence of obstruction is 1.3 to 10.2% (2-4). It may occur early or late. Early obstruction may
result from distal obstruction, clot, oedema, or technical problems associated with the
ureteroneocystostomy. When Foley catheter placement and expectant management does not resolve
the problem, surgical revision of the ureteroneocystostomy over a stent may be required. Late
obstruction, when not caused by external compression (e.g. lymphocoele, pregnancy), is associated
most typically with fibrosis or nephrolithiasis. Management typically is by radiological or cystoscopic
stent placement and stricture dilatation.
73

6. Urine leak can occur at any level of the urinary tract, from the renal pelvis to the urethra. The reported
incidence of urinary leak is 1.2 to 8.9% (4-7). Fluid around the transplant during the first 24 hours
following transplantation is an urinoma and results from a leak between the renal transplant ureter and
the recipient's bladder. Patient is oliguric or even anuric. Such a leak may be the result of surgical failure
or from necrosis of the distal portion of the transplant ureter. An urinoma enlarges more slowly and
remains hypoechoic. If the urinoma becomes infected the quality of the fluid may become more complex
as an abscess forms. After several weeks a spontaneous haematoma or an urinoma becomes less
likely. Suspect urine leak when a patient with good or improving graft function develops a fluid leak from
the wound or abdominal pain or perineal swelling, typically within a month of transplantation. Fluid
leaking from the wound can be collected and assayed for creatinine. Nuclear renal scan probably is the
most sensitive test for urine leak. Small bladder leaks often can be managed by bladder decompression
with a Foley catheter. Larger and more proximal leaks typically require exploration and repair.
7. Leakage from perivascular lymphatic vessels can lead to significant collections of lymph between the
lower pole of the transplanted kidney and the bladder. A lymphocoele may form anywhere in the general
area of the renal transplant. While lymphocoeles are more likely to occur soon after the transplant, they
may develop long after the skin wound has healed. An uncomplicated lymphocoele is hypoechoic and
remains hypoechoic unless it becomes infected. While lymphocoeles are slow to develop, a
lymphocoele can create significant pressure resulting in urinary or venous obstruction. Lymphocoele
can manifest as swelling, pain, and impaired renal function within the first year following transplantation.
Frequency of lypmphocoeles varies from 5 to 36% (1,8-9). Ultrasonography (US) or CT scan
demonstrates the collect well and facilitates planning treatment. Aspiration occasionally resolves the
problem, but prolonged catheter drainage is associated with a significant risk of infection. Sclerotherapy
with 10% povidone-iodine solution may be successful in small unloculated collections, but lymphocoele
has a high rate of recurrence. Some early success has been observed on instilling fibrin glue containing
gentamicin and iodine solution. However, the current standard of care is internal drainage of the
lymphocoele into the abdominal cavity. This increasingly is performed laparoscopically.
8. Infection of transplanted kidney or wound and other tissue infections are possible. An abscess may
develop at any time during the life history of a renal transplant recipient. Abscesses may be around the
kidney, within the transplant, or in the abdominal cavity remote from the transplant. Most abscesses
have complex sonographic qualities. An abscess can be diagnosed best by comparing the sonographic
texture of a fluid collection to the white blood cell count and the patient's fever curve. In cases in which
an abscess is considered likely, sonographically guided aspiration is recommended. Diagnostic
ultrasound may both initially diagnose the fluid mass as well as guide the surgical or radiologically based
drainage. If percutaneous drainage results in a recurrence of a lymphocoele, laparoscopic drainage is
indicated.
9. With improved immunosuppression, acute rejection has become less of a problem following
transplantation. In the first year following transplantation, acute rejection is observed in approximately
25% of patients( 5,12). Rejection usually is asymptomatic, although it sometimes presents with fever and
pain at the graft site. Rejection usually presents as an unexplained rise in serum creatinine and can be
confirmed with biopsy. Biopsy under ultrasonography control should be performed. Typical biopsy
findings of acute cellular rejection include a lymphoplasmacytic infiltration of the renal interstitial areas
with occasional penetration of the tubular epithelium by these cells. Most rejection episodes can be
treated successfully with a short course of increased steroids. Failure to respond to steroid therapy for a
particularly aggressive appearance on biopsy may prompt a change of treatment strategy (e.g.
antilymphocyte antibody agents).
10. Chronic rejection appears to have both immunologic and nonimmunologic components. As a broad
classification for progressive graft failure, risk factors include initial poor function of the graft and a
history of acute rejection episodes (12).
Most initial complications can be corrected if detected promptly. The radiologist should help to select the
most effective imaging methods for evaluating the many problems encountered in renal transplantation.
74

In the author's experience, ultrasonography (US) is a safe, rapid, and portable means to first detect most
surgical emergencies.
Nuclear medicine scanning and flow studies remain the primary means for evaluating vascular supply to the
transplant after surgery and for confirming urinoma. The main advantage of nuclear medicine scans is that
they demonstrate the pathophysiology involved. Recent developments in Doppler US and MRI show promise
in improving the quality of renal vascular imaging without the use of potentially nephrotoxic intravenous (IV)
contrast materials.
CT scanning and CT-guided interventions remain an important means for examining the preoperative renal
donor candidate and for evaluating the complications that develop in patients who undergo renal transplants.
The complementary nature of nuclear medicine studies and US in the imaging evaluation of hydronephrosis,
renal artery stenosis, flank pain, renal masses, pyelonephritis, and kidney transplant was confirmed. In more
recent years, MRI of the abdomen has evolved into an excellent alternative means for the diagnosis of most
renal transplantation complications and for the examination of the living related donor. The contrast agents
used for MRI are nontoxic to the transplanted kidney, and MRI often can be used to assess renal function,
vascular supply, and postoperative complications. However, MRI remains expensive and may be
contraindicated in certain patients. Whenever two or more diagnostic techniques are used in the diagnosis of
renal transplantation, comparison between the techniques is often very useful. Comparison of recent, current
studies with remote, prior examinations is critical. New fluid collects are of greater significance than are
slowly resolving fluid collections.
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after kidney transplantation. Transplant Proc 1990; 22:1423-1424.
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11. Kräłl R, Cierpka L, Ziaja J, et al: Surgically treated early complications after kidney transplantation. Transplant Proc 2003; 35: 2241-
224.
12. Amend WJC, Jr, Vincenti F, Tomlanovitch JS. The first three posttransplant months. In: Danovitch GM, ed.Handbook of kidney
transplantation.4 th ed. Philadelphia: Lippincott Williams&Wilkins; 2005: 212-233.
ACUTE RENAL FAILURE: IMAGING EVALUATION OF NATIVE KIDNEYS
O Hélénon and JM Correas
Necker hospital, Paris, France
Acute renal failure (ARF) is a clinically defined syndrome characterized by a rapid (over a period of hours of
days) decline in renal function. From a clinical and pathophysiological point of view, it is subclassified into
three distinct categories: 1) prerenal failure defined by a reversible physiologic response to renal
hypoperfusion with preserved renal integrity; 2) intrinsic renal failure secondary to a disease of the renal
parenchyma or vasculature; 3) postrenal failure due to an obstructive uropathy.
Among imaging techniques, ultrasonography plays an important role in the first step evaluation of ARF.
Doppler ultrasound (US) and contrast-enhanced MR imaging also can give an effective assistance in the
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differential diagnosis of ARF, especially in patients with suspected acute intrinsic renal failure of renovascular
origin.
1 First step US evaluation of ARF
A review of the clinical history and symptoms, the laboratory data (urinalysis, urine and serum chemistry
levels) and the result of ultrasound (US) commonly identify the mechanism that is involved in the
development of ARF. In this first step clinical approach the morphological informations needed are simply
and promptly obtained by gray scale US that determine the size of the kidneys and screen for urinary tract
obstruction. Usually the size of the kidneys is normal or moderately increased with smooth margins. The
presence of small kidneys suggests underlying chronic nephropathy.
1.1 Diagnosis of obstructive renal failure (postrenal ARF)
Whereas the dilatation of the excretory system does not necessarily mean obstruction (ie. elevation of the
collecting-system pressure), bilateral dilatation or a dilated collecting-system in a solitary kidney at US in a
patient with ARF strongly suggest a postrenal mechanism. Unilateral dilatation also may be responsible for
ARF when it occurs in patients with underlying chronic renal disease involving both kidneys or the contra
lateral kidney. US has an excellent sensitivity for diagnosing hydronephrosis especially in the screening for
obstructive ARF since most of false negatives are due to the lack of dilatation in very early acute renal
obstructions. On the other hand pitfalls such as parapelvic cysts and normal variants including extrarenal
pelvis, megacalyces and enlarged lobar venous system, may mimic a dilatation of the intrarenal collecting
system and lead to a false positive result. The recognition of a dilated collecting system therefore relies on
the presence of dilated calyces within mid and polar portions of the sinus with continuity toward a dilated
renal pelvis in a central position. Color Doppler US may help rule out prominent vessels within the renal sinus
in some difficult cases.
1.2 Diagnosis of the obstructive disease
Since postrenal failure is suspected, US should provide additional information on the level and the
mechanism of obstruction on the urinary tract. The cause sometimes can be identify by US such as bladder
outlet obstruction due to BPH, infiltrative bladder carcinoma with bilateral ureteral involvement, pelvic
neoplasm or enlarged lymph nodes with ureteral compression or tumor invasion. Usually the results of this
first step US and clinical evaluation in a patient presenting with postrenal failure lead to appropriate treatment
which consists in the mechanical relief of obstruction using foley catheterization, retrograde ureteral
catheterization or percutaneous nephrostomy depending on the level and the mechanism of obstruction.
Following relief of obstruction and management of postobstructive diuresis accurate diagnosis and evaluation
of the obstructive uropathy can be obtained using contrast-enhanced CT or MRI especially in gynaecologic
etiologies.
2 Differential diagnosis of nonobstructive ARF
The demonstration of a non dilated urinary tract leads to differential diagnosis among prerenal ARF and
different causes of intrinsic acute renal failure.
Alteration of the parenchymal echogenicity and especially increased echoginicity of the renal cortex (with
increased corticomedullary contrast gradient) indicates a renal parenchymal disease but without information
on its specific nature. Recognition of such a pattern is based on the subjective interpretation of the examiner
and has a poor clinical interest in routine practice.
At this stage of the diagnostic strategy, US using color and pulsed Doppler plays a major role especially in
the diagnosis of vascular disorders. In such an indication it requires an experienced operator and skill hands
to obtain efficient information and discriminate renal parenchymal diseases from vascular disorders.
2.1 Renal parenchymal diseases versus prerenal azotemia
Whereas, the diagnosis of prerenal ARF is commonly based on anamnesis, laboratory data and the
response to treatment (restored plasma volume or pressure), Doppler US may help differentiate acute
tubular necrosis (ATN) from prerenal azotemia. Elevation of resistive indices (RIs) greater than or equal to
0.75 is reported to occur in 91% of patients with ATN whereas RI remains normal (< 0.70) in most of patients
with prerenal azotemia except patients with severe liver disease responsible for hepatorenal syndrome. RI
values also may help discriminate micro vascular causes of ARF including renal vasculitis, ARF
accompanying malignant hypertension and drug-induced interstitial nephritis, associated with markedly
76

elevated RI, from prerenal pathologic conditions (with the exception of hepatorenal syndrome) and acute
glomerulonephritis which do not significantly increase RI values (table 1). Such information on renal arterial
resistance is however non specific and does not obviate renal needle biopsy which remains indicated to
establish the correct diagnosis and its histopathologic nature.
2.2 Vascular disorders vs renal parenchymal diseases
Among vascular causes of ARF (other than micro vascular disorders), the diagnosis of ischemic disorders
including cortical necrosis and infarction, can benefit from US using color Doppler imaging and contrastenhanced
non linear gray-scale US, and contrast-enhanced MRI. Both techniques can provide accurate
assessment of renal perfusion defects either with segmental or more diffuse distribution.
Acute pedicular arterial lesions such as acute renal artery dissection or atherosclerotic thrombosis also can
be responsible for ARF especially in patients with underlying chronic renal failure. In such circumstances
Doppler US reveals absence or a marked decrease in color Doppler signal or a tardus-parvus Doppler
waveform (ie. Slowed flow and loss of systolic-diastolic modulation from interlobar arteries) distal to the
arterial occlusion.
In acute renal vein thrombosis that is suspected in case of nephrotic syndrome associated with ARF and
inconstant lumbar pain Doppler US may reveal increased RIs in the involved kidney, sometimes with
reversed diastolic flow. However, the correct diagnosis relies on the demonstration of a non or partially
flowing renal vein with echoic material lying within the lumen usually without venous enlargement.
Arterial intrarenal Doppler spectrum
Causes of non obstructive ARF
PRERENAL AZOTEMIA
Absolute blood volume depletion
Normal
Elevated
RI
Tardusparvus
Hemorrhage +
Gastrointestinal losses (diarrhea,..)
Renal losses (diuretics,..) +
Third spacing (burns,..) +
Relative decrease in blood volume
Peripheral vasodilatation (shock,..) +
Hepatorenal syndrome +
Compromised cardiac function
Recent myocardial infarction +/-
Cardiac tamponade +/-
Cardiac or arrhythmia +/-
Disruption in renal autoregulation
ACE inhibitor +/-
ACUTE INTRINSIC RENAL FAILURE
No signal
Acute tubular necrosis +
Drug-induced nephritis +
Acute glomerulonephritis +
Microvascular diseases and vasculitis
Nodose panarteritis +
Hemolytic-uremic syndrome +
Thrombotic thrombocytopenic purpura +
Cholesterol emboli +
Malignant hypertension +
Renal cortical necrosis +
Large renal vessels occlusion
Acute RA dissection +
Acute RA embolism + + (necrosis)
Atherosclerotic RA occlusion
+ (necrosis)
Large segmental infarction +
Acute RV thrombosis + + (necrosis)
Table 1: Causes of non obstructive ARF with Doppler US correlation (pulsed Doppler from intrarenal
arteries). RI: resistive index; ACE: angiotensin converting enzymz; RA: renal artery; RV: renal vein.
77

THE TRANSPLANTED KIDNEY: RENAL EMERGENCIES
Jarl Å. Jakobsen
MD, PhD, MHA, Department of Radiology, Rikshospitalet University Hospital,
N-0027 Oslo, Norway.
INTRODUCTION
It is a continuous challenge to make donor kidneys available. Further, undergoing transplantation is a major,
stressful event for the patients, the donor, and the family of a donor. Therefore, nothing should be avoided to
make the correct diagnosis and give the right treatment to prevent acute loss of graft function.
THE CLINICAL PROBLEMS
The most common findings prompting an emergency radiological procedure are increased serum creatinine
(more than 20 %), oliguria or tenderness and swelling over the transplanted kidney. Severe, new, and
progressive hypertension resistant to medication may also cause examinations for renal artery stenosis.
Occasionally, hematuria can be the indication for acute imaging.
During the immediate postoperative period (up to 1 week posttransplantation), failure of the graft function is
usually due to surgically related problems, to acute tubular necrosis (ATN), and hyperacute rejection. The
early problems occur between 1 and 4 weeks after transplantation. Acute rejection and urinary leakage are
most common. Thrombosis of the renal artery or vein can also be found. Later (after 1 month), acute and
chronic rejection as well as lymphocoeles, ureteric stricture, renal artery stenosis, intercurrent infections and
recurrence of primary kidney disease dominate the pathological findings. Medication toxicity is usually well
controlled for now.
IMAGING
Ultrasonography
Ultrasonography with Doppler is usually the first examination of the failing graft, allowing a quick and noninvasive
assessment of the kidneys form and size, echogenicity, dilatation of the collecting system, and any
fluid collections or mass lesions in the lower abdomen.
In ATN, the kidney may appear normal, but findings in severe cases include enlarged and hypoechoic kidney
with loss of the normal cortico-medullary junction. The renal sinus echoes may be compressed.
The findings in acute kidney transplant rejection consist of globular enlargement of the kidney, swelling and
hypoechogenicity of the medullary pyramids, indistinct cortico-medullary junction, foci in the renal cortex and
oedema of the collecting system wall.
Dilatation of the calyces and the renal pelvis is easily seen, but a slight dilatation is common in the
transplanted kidney without obstruction. When dilatation is diagnosed, the cause is often found during further
scanning of the surrounding tissue and the urinary bladder. In any case of dilatation concomitant with a full
urinary bladder, scanning must be performed immediately after voiding.
Doppler
Both spectral, colour, and power Doppler may give important information about the transplanted kidney. The
main use of Doppler is to assess open arteries and veins, and provide the location of interlobar vessels for
further evaluation with spectral Doppler. Stenosis at the site of the arterial anastomosis occurs in 1 % - 23 %,
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
upper normal limit of velocities. Arterio-venous (AV) fistulas occur after renal transplant biopsies with a
frequency between 10 % - 20 %, while pseudoaneurysms are uncommon. Colour Doppler is probably best
for detection of the vascular lesion as the focus with colour aliasing is easily seen. Spectral analyses of the
feeding artery, the fistula and the vein is necessary to confirm the specific diagnosis.
The spectral Doppler curves, usually from interlobar arteries, are used for calculating resistance index (RI).
Changes in RI are sensitive, but not specific for the most important causes, namely acute rejection. Reasons
for increased RI can be simplified into prerenal, intrarenal, perirenal or postrenal categories (Table 1).
A cut-off at 0.75 for RI seem to have a good sensitivity and fairly acceptable specificity for detection of acute
rejection, given that other causes are eliminated. Some authors regard the range between 0.70 and 0.79 as
an indeterminate group. In one large study, an RI index of 0,80 or higher was shown to indicate increased
risk for graft failure and increased patient mortality in the long term. However, ATN can also increase RI.
78

Diagnosis of rejection based on an elevated resistance index should be made with caution in the presence of
a perinephric mass or hypotension. Furthermore, care should be taken while performing the study not to use
excessive manual pressure on the kidney because this may yield a falsely elevated resistive index.
An increase in heart rate will decrease the RI. Transplant renal artery stenosis (TRAS) may also result in a
low RI. However, although it is a highly specific finding, the sensitivity for the diagnosis of TRAS is low.
Infarctions in the renal poles may occur, and is seen as areas without flow on colour and power Doppler.
Contrast-specific sequences together with ultrasound contrast agents (USCA) can improve the sensitivity
and accuracy. Techniques are now available using USCA to assess perfusion in the transplant, but the
clinical use is not yet established.
In chronic rejection can loss of cortical flow be demonstrated with colour Doppler, and especially using power
Doppler due to the increased sensitivity for flow.
Magnetic Resonance Imaging (MRI)
With MRI, good images differentiating the cortex from the pyramids are usually obtained. Using MR contrast
in combination with fast sequences provides perfusion images, and is a supplement to indeterminate Doppler
findings when a segmental infarction is suspected.
MR urography (hydrography, MRU) is
performed without any contrast Table 1. Reasons for elevated resistance index.
agents, using fast, heavily T2-
weighted sequences. In addition, a fatsuppression
pulse can be used to
Level of pathology
Prerenal
Pathology
Hypotension
minimize unwanted effects of
Renal vein thrombosis
surrounding retroperitoneal fat. MRU
Bradycardia
can provide excellent overview of the
Intrarenal
Acute tubular necrosis
urinary collecting system including any
Acute vascular rejection
filling defects in the urinary bladder.
Chronic vascular rejection
The site of urinary leakage can usually
be diagnosed more often by MR than
Cyclosporine toxicity
by ultrasound.
MR angiography (MRA), both without
and with MR contrast agents, may also
be used to evaluate the vascular
pedicle. A negative finding when
suspecting renal artery stenosis has
high accuracy, but one should be
aware of false positive diagnoses
when estimating the degree of a
stenosis found.
Computed Tomography (CT)
Perirenal
Postrenal
Glomerulonephritis
Pyelonephritis
Hematoma
Manual compression of transducer
Acute obstruction
Due to the potential nephrotoxicity of contrast media, CT is seldom used. CT gives, however, a good
visualisation of fluid collections, and can also be indicated in order to assess mass lesions within the kidney.
CT angiography with multislice equipment can be used for assessing vascular complications like renal artery
stenosis.
Conventional angiography
Angiography should be reserved for those patients where vascular intervention is needed to treat a condition
diagnosed using non-invasive modalities.
INTERVENTION
Biopsy
Biopsy is the most common percutaneous procedure on the renal transplant. The biopsy is needed to
differentiate between various important parenchymal causes for acute failure. The biopsy is performed under
ultrasound guidance, and taken with an automated biopsy gun and an 18 G thru-cut needle. The biopsy is
taken from the cortex at the lower pole, and not from any part of the medulla. Prior to the puncture, colour
Doppler is always done to confirm circulation of the area, and to avoid puncturing interlobar and segmental
arteries or arterio-venous fistulas from previous biopsies.
The quality of the biopsy should be assessed immediately by counting glomeruli using a suitable microscope,
so that enough material is obtained in one procedure. Usually, one to three specimens are needed. The
79

iopsies can be evaluated by pathologists using light and electronic microscopy. Recently, it has been shown
that similar appearance in light microscopy can be further classified due to their gene expression into three
classes that are predictive for the long-term prognosis.
In a few patients complications to biopsy, like arterio-venous fistulas, perirenal and subcapsular hematomas,
occur. While the AV-fistulas usually heal spontaneously, some of them require embolisation. Hematomas
may often require percutaneous or surgical drainage.
Pyelography, intervention to the ureter, and nephrostomy
These methods are usually applied for diagnosis and treatment of dilated collecting systems and fluid
collections, and will be covered elsewhere. This includes also ureteral strictures.
Vascular intervention
Vascular intervention can be used to treat renal artery stenosis, AV-fistulas, and bleeding after biopsy or
pyelostomy.
Conclusion
Imaging of the acute failing transplanted kidney is usually based on ultrasound and Doppler examinations.
Ultrasound contrast agents have a potential to further sophisticate the examination. Pecutaneous biopsy is
frequently necessary. Comprehensive MR examinations are very promising. However, all the other
modalities must be used to some extent. Most of the percutaneous interventional procedures and advanced
vascular intervention should be available.
THE TRANSPLANTATED KIDNEY: EXTRARENAL EMERGENCIES
Nicolas Grenier
Service de Radiologie, Groupe Hospitalier Pellegrin, Bordeaux, France
Progress in immunotherapy allowed increasing the number of transplanted kidneys in the recent years.
Ultrasonography (US) (using B-mode and Doppler techniques) and magnetic resonance imaging (MRI) are
the two major techniques for follow-up of transplanted kidneys, making it possible to avoid nephrotoxic
contrast agents. Clinical emergencies following transplantation related to extrarenal causes include anuria
secondary to acute obstruction of the pyelocaliceal system by urolithiasis or retroperitoneal collection,
retroperitoneal hemorrhage related to arterial complication, sepsis related to retroperitoneal abcesses,
thrombophlebitis on the side of transplant. Most causes of extrarenal emergencies are important to recognize
because often require a surgical management.
RETROPERITONEAL HEMORRHAGE
Hematomas account for approximately 9% of peritransplant collections and occur usually in the postoperative
course, due to surgery. The other main causes are:
- early renal biopsy complicated by a cortical pseudoaneurysm which may enlarge and subsequently
rupture in the perirenal space; this complication occurs immediately (24-48h) or several weeks after biopsy;
- a graft rupture secondary to severe acute rejection. It occurs in 3% to 6% of renal transplants and the
first two weeks after transplantation. This diagnosis must be suspected when are associated to anuria, an
abdominal pain at the graft level, swelling upon the graft and hypotension or shock.
- some causes are more exceptional as breakdown of the arterial anastomosis or rupture of an arterial
aneurysm (mycotic or not).
Hematomas appear as perirenal iso- or hyperechoic collections, without flow on color flow sonography, with
an intermediate SI and a mixed and inhomogeneous SI on T1w and on T2W images, respectively. An
extravasation of contrast agent can be visualized either with sonography, after injection of microbubbles or
with MR imaging, after Gd injection. Pretherapeutic MR-angiography is useful to demonstrate the cause of
hematoma, and more specifically, the arterial complications as aneurysms or pseudoaneurysms.
According to the cause, these hemorrhagic complications must be managed either surgically if the cause is a
rupture of the graft or a rupture of the arterial anastomosis, or radiologically, by embolisation, if the cause is a
ruptured pseudoaneurysm or an arteriovenous fistula. If the hematoma is sufficiently large to produce
ureteral obstruction, surgical evacuation is mandatory.
80

ANURIA
Anuria following transplantation can be due to an intrarenal or to extrarenal causes. Among extrarenal
causes, post-operative hematomas and necrosis of the low ureter are the most frequent in the acute phase
after transplantation and ureteral obstruction in the later phase.
Causes of early obstructive anuria
Necrosis of the lower ureter may occur in the early post-operative period. It produces a retroperitoneal
urinoma or, exceptionally, an intraperitoneal extravasation of urine. Post-operative ischemia and subsequent
necrosis of the lower ureter due to impairment of its arterial blood supply during organ removal. The
incidence of this complication varies between 3 % and 10%. It. The other cause of massive urine
extravasation is the breakdown of the ureteroneocystostomy which is more unusual. Whereas separation of
the two causes is difficult radiologically, both require an urgent surgical correction.
Sonography finds an anechoic collection at the lower pole of the kidney or intraperitoneal fluid. This fluid
appears simple on non-enhanced MR T1 and T2w sequences. T2w-MR urography shows the collection and
the entire dilated excretory system. However, the diagnosis requires to demonstrate extravasation of contrast
medium after IV injection. This can be obtained using Gd-enhanced MRI or iodine-enhanced CT.
Contamination of urine collection by the contrast agent requires often delayed imaging (5 to 15 minutes after
injection).
These other causes of early obstructive anuria are infrequent: obstruction by a clot during hematuria, edema
of ureteral anastomosis, twist of the ureter after intraperitoneal implantation, acute hematoma (see above).
Causes of delayed obstructive anuria
Causes of delayed ureteral obstruction can be acute, dominated by migrated urolithisasis, or chronic,
dominated by delayed collections, ureteral stricture or extrinsic obstruction. Both require an adequate
urological or radiological treatment to restore a normal renal function. Urolithiasis is an unusual complication
occurring in less than 1% of recipients, at least 6 months after transplantation. When ureteral, it may be
complicated by acute obstruction, infection, or urinary leak secondary to erosion of the uroterovesical
junction by the stone. Stones can be detected by sonography, CT or MRI.
The other causes of obstruction (lymphoceles, perirenal or hilar fibrosis, urothelial tumors…) usually o not
produce acute anuria and are not considered as emergencies.
ACUTE SEPSIS
Post-operative infection can be responsible for perirenal septic collections. Pelvic pain and graft tenderness
are associated with fever and increased blood white cells. However, immunosuppression may attenuate
these clinical and biological changes. Sonography shows a perirenal collection with thin or coarse echoes,
often extended towards superficial planes. Exact extension of such collections must be assessed by MR
imaging: the content appears as slightly hyperintense on T1w images and intermediate on T2w images; Gdenhanced
sequences shows a peripheral wall enhancement, characteristic of septic collections. Treatment
can be performed surgically or percutaneously with catheter drainage and general antibiotherapy.
THROMBOPHLEBITIS
Acute venous thrombosis of lower limbs may occur postoperatively. The risk of this complication is the
extension of thrombus to the graft renal vein with a risk of graft loss if the diagnosis and the treatment are
delayed. Ipsilateral acute thrombosis is the main cause of renal vein thrombosis after transplantation.
Therefore, such clinical suspicion must justify the realization of sonography including the veins of lower
limbs, iliac veins and the renal vein. The diagnosis of renal vein thrombosis is difficult. On sonography, the
direct extension of the iliac thrombus can be visualized, causing a severe increase of resistive index with a
decreased flow and a protodiastolic or a holodiastolic reflux.
EXTRAURINARY EMERGENCIES
Other intra-abdominal emergencies, mainly digestive, are very unususal and can be observed after
intraperitoneal implantation of renal grafts. These are non specific of renal transplantation.
81

Chest
The immunocompromized transplanted patient is susceptible to pulmonary infections due to either common
pathogens, viruses or rare opportunistic germs. Cytomegalovirus is the most common virus associated with
pulmonary infections inthese patients. Viral pneumonia begin by patchy interstitial infiltrate, progressing to
lobular consolidation.
Abdomen
Adynamic ileus is possible in the post-operative period. Main digestive complications are gastroduodenal
ulcerations and acute pancreatitis. Colonic perforation due to diverticulitis is most frequent in patients with
autosomic dominant polycystic disease. Finally, involvement of the large bowel by CMV may cause
ulceration and colonic bleeding.
CONCLUSION
Diagnostic imaging plays a major role in identification of extrarenal emergencies using US and MRI for
urinary complications and other techniques for extra-urinary complications. Interventional procedures can be
proposed as an alternative to surgery in many circumstances.
References
- Letourneau JG, Day DL, Ascher NL. Radiology of organ transplantation. Mosby, St Louis, 1991
- Dodd GD, Tublin ME, Shah A, Zajko AB. Imaging of vascular complications associated with renal transplants. AJR 1991; 157:449-459
- N. Grenier, M. Claudon, H. Trillaud, C. Douws, O. Levantal Noninvasive imaging of vascular complications in kidney transplants. Eur
Radiol 1997; 7:385-391
- Neimatallah MA, Dong Q, Scheonberg S, Cho KJ, Prince MR. Magnetic resonance in renal transplantation. JMRI 1999; 10 :357-368
82

WORKSHOPS
RF ABLATION OF RENAL TUMORS
Peter L. Choyke, M.D.
National Cancer Institute, Bethesda, Maryland, USA
The advent of cross sectional imaging radically changed the nature of renal cancer therapy. Whereas, prior
to cross sectional imaging renal tumors presented with clinical symptoms, often at an advanced stage, after
the introduction of cross sectional imaging, the number of small and asymptomatic renal tumors dramatically
increased and the 5 year survival statistics for renal cancer similarly improved. Many of these incidental
tumors were cured by surgical removal. As more of these tumors were removed by radical nephrectomy,
surgeons and patients rapidly began to question whether nephron sparing procedures might not make more
sense. The introduction of laparoscopic partial nephrectomy meant even less invasive procedures for the
patient. The logical next step was the introduction of minimally invasive treatments requiring only light
sedation and no hospital stay. Thus, was born Radiofrequency ablation (RFA) and cryotherapy for renal
tumors.
Radiofrequency ablation is itself an extension of a well known property of tissue to undergo coagulative
necrosis when exposed directly to high frequency energy if the body is electrically grounded. The Bovie
coagulator, operating on the same principle has been used for over 30 years during surgical procedures to
stem the loss of blood by coagulation. The technical challenge for RFA was to build radiofrequency probes
that created a uniform sphere of evenly heated tissue without charring the tissue. Charring leads to an
insulating effect that inhibits heat transfer, limiting the killing of cells. Pulsed RF and cooled RF were
developed to prevent charring. With sufficient power these probes can effectively ablate fairly large spheres
of tumor [1].
A companion method of ablation, cryotherapy, involves the installation of liquid nitrogen through a heat
transfer probe. A spherical iceball forms at the tip of the probe. The freezing of the cytoplasm leads to
expansion and crystallization of intracellular contents both of which tend to rupture cell membranes, however,
the true killing effect does not occur until thawing occurs. Thus freeze-thaw cycles are required for effective
cell killing [2].
Image Guidance
Both RFA and Cryoablation require image guidance. Some centers rely exclusively on ultrasound but most
centers utilize some combination of CT, MRI or Ultrasound to place the probe accurately. In our center, CT
is mostly used to guide the probe into the tumor. For RFA there is no means of monitoring heat generation in
real time for CT or ultrasound. Research has suggested that MRI (observing changes in the T1 or phase of
heated tissue)could provide real time heating assessment of the RFA, however, there are substantial
technical challenges simply to make MR compatible RF probes and then to operate such probes in the MR
environment [3]. Cryotherapy has the distinct advantage of demonstrating changes, obvious on MRI by the
absence of signal or on CT as a decrease in attenuation during the ice ball. Both MRI and CT aid in the
guidance of these minimally invasive therapies [4].
Patient Selection
Like all procedures in medicine, care should be exercised in selecting patients. Even with the considerable
experience of RFA and cryotherapy worldwide, these procedures are still not considered the gold standard
for therapy of renal cancer. However, they have become more universally accepted in a variety of situations.
Patients with hereditary renal cancers in whom repeated surgical procedures would otherwise be necessary
are good candidates for RFA/cryo [5]. Similarly, elderly patients who require treatment but who are high risk
for surgery and patients with single kidneys in whom surgery could result in loss of the remaining kidney are
good candidates for RFA/cryo. Other indications include massive hematuria due to tumor bleeding [6].
83

Tumor location plays a role in patient selection. Peripheral lateral tumors are ideal as a clear path to kidney
tumor can be found without interfering structures. Deeper tumors can be problematic because of the heat
sink effect caused by large vessels in the renal sinus. The patient must be prepared to undergo surgery of
this lesion if it recurs after RFA/cryo. Another complication of treating deep lesions is the trapped calyx
caused by the inadvertent occlusion of the upper or lower pole collecting system. Similarly lower pole
exophytic tumors or tumors near the renal hilum can lead to hydronephrosis and obstruction if the ureter or
pelvis is included in the treatment field [7]. This complication can be difficult to treat and may require
extended stenting and/or surgical repair.
Patients with bleeding disorders or immunologic disorders are relatively contraindicated as bleeding and/or
infection can occur.
Procedure
The RFA/cryo procedure usually takes less than one hour. Intravenous conscious sedation with local
anesthesia is desirable. The skin is prepped and draped and a biopsy needle is placed within the tumor. This
material is sent for histologic analysis. In some centers RFA/cryo does not proceed until the diagnosis has
been made by the pathologist [8]. Our approach is to obtain the biopsy but proceed to the treatment at the
same time. It should be noted however, that a high percentage (up to 20% in one study) of incidentally
detected renal masses were benign. For lesions adjacent to bowel a “cushion” of fluid can be instilled to
separate the lesion from the bowel [9].
Treatment with RFA/cryo is dependent on the success of tissue heating/freezing. Thermistors in the RF
probe indicate the temperature at the periphery of the treated tissue but can be misleading. Imaging can be
used to ascertain the size and shape of the iceball during cryo. It is possible to treat multiple lesions at one
session.
The patient is observed for a period of hours after the procedure. Generally, after recovery from anesthesia
they can be discharged home. Some are better off with an overnight stay if the procedure begins in the
afternoon. Usually discharge is possible by the next day. Occasionally, the patient may have pain associated
with procedure, usually it is relieved by analgesics.
Follow-up
It is vital that the patient be checked periodically to insure that the lesion was satisfactorily treated. We
generally obtain our first post treatment study at 3 months. We perform pre and post contrast scans (arterial
and venous phase). A successful treatment will demonstrate a lesion slightly denser than renal parenchyma
(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,
methods of amplifying the effect within the kidney tumor while minimizing the effect in normal tissue is being
considered with certain targeted therapies that render the tumor more vulnerable to heating or freezing.
Better methods of monitoring kidneys for early recurrent disease such as with PET scanning are under
evaluation. The minimally invasive treatment of larger renal tumors is also being considered using multiprobe
arrays. These developments offer hope for the future that therapies can be delivered with minimal
discomfort and inconvenience to the patient.
1. Mayo-Smith WW, Dupuy DE, Parikh PM, Pezzullo JA, Cronan JJ. Imaging-guided percutaneous radiofrequency ablation of solid renal
masses: techniques and outcomes of 38 treatment sessions in 32 consecutive patients. AJR Am J Roentgenol. 2003 Jun;180(6):1503-
8.
2. Finelli A, Rewcastle JC, Jewett MA. Cryotherapy and radiofrequency ablation: pathophysiologic basis and laboratory studies. Curr
Opin Urol. 2003 May;13(3):187-91.
3. Lewin JS, Nour SG, Connell CF, Sulman A, Duerk JL, Resnick MI, Haaga JR. Phase II clinical trial of interactive MR imaging-guided
interstitial radiofrequency thermal ablation of primary kidney tumors: initial experience. Radiology. 2004 Sep;232(3):835-45.
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
5. Pautler SE, Pavlovich CP, Mikityansky I, Drachenberg DE, Choyke PL, Linehan WM, Wood BJ, Walther MM. Retroperitoneoscopicguided
radiofrequency ablation of renal tumors. Can J Urol. 2001 Aug;8(4):1330-3
6. Neeman Z, Sarin S, Coleman J, Fojo T, Wood BJ. Radiofrequency ablation for tumor-related massive hematuria. J Vasc Interv Radiol.
2005 Mar;16(3):417-21.
7. Rhim H, Dodd GD 3rd, Chintapalli KN, Wood BJ, Dupuy DE, Hvizda JL, Sewell PE, Goldberg SN. Radiofrequency thermal ablation of
abdominal tumors: lessons learned from complications. Radiographics. 2004 Jan-Feb;24(1):41-52
8. Farrell MA, Charboneau JW, Callstrom MR, Reading CC, Engen DE, Blute ML. Paranephric water instillation: a technique to prevent
bowel injury during percutaneous renal radiofrequency ablation. AJR Am J Roentgenol. 2003 Nov;181(5):1315-7
9. Tuncali K, vanSonnenberg E, Shankar S, Mortele KJ, Cibas ES, Silverman SG. Evaluation of patients referred for percutaneous
ablation of renal tumors:importance of a preprocedural diagnosis.AJR Am J Roentgenol. 2004 Sep;183(3):575-82
10. Goldberg SN, Grassi CJ, Cardella JF, Charboneau JW, Dodd Iii GD, Dupuy DE, Gervais D, Gillams AR, Kane RA, Lee FT Jr, Livraghi
T, McGahan J, Phillips DA, Rhim H, Silverman SG. Image-guided Tumor Ablation: Standardization of Terminology and Reporting
Criteria. Radiology. 2005 Apr 21; epub
DIAGNOSIS OF PROSTATE CARCINOMA: (IS THERE A) ROLE FOR THE
RADIOLOGIST (?)
R.H. Oyen
Department of Radiology, University Hospitals Gasthuisberg
Katholieke Universiteit Leuven
Raymond.oyen@uzleuven.be
The current situation
The current situation in prostate imaging, in particular in transrectal ultrasound (TRUS) of the prostate gland
is different in different countries, and in the same country there are differences amongst the hospitals. Most
often, TRUS of the prostate is performed by urologists. Their major arguments include a) their experience in
performing digital rectal examination of the prostate gland, b) the fact that it is an ‘endoluminal’ procedure,
and c) the fact that TRUS-guided-biopsies of the prostate are an essential part of the procedure. Indeed, the
ultimate diagnosis or confirmation of prostate carcinoma is still based on histological examination of TRUSguided
biopsy cores either targeted at hypoechoic peripheral zone lesions or/and obtained by any set of at
random biopsies.
CT and MR imaging of the prostate glands or in men with prostatic carcinoma is almost exclusively
performed by radiologists.
Radiologists and TRUS
Even though the majority of TRUS-examinations of the prostate is in the hands of urologists, radiologists
must gain experience with TRUS to serve referred patients for prostatic ultrasonography in the best possible
way, including the performance of TRUS-guided biopsies.
The prostate is a parenchymatous organ comparable to other organs prone to ultrasound examinations
(perhaps best comparable to another urological structure, the kidney). Therefore, as with other organs and
structures, knowledge of the normal anatomy, the understanding of different disease processes involving the
85

prostate gland, and the use of dedicated equipment are essential prerequisites to achieve high quality
examinations and reports.
Radiologists are trained to detect focal lesions in parenchymal organs. This experience can be extended to
the prostate gland to detect focal lesions in the peripheral zone to improve the sensitivity of TRUS and to
improve the yield of TRUS-guided biopsies.
Many radiologists have large experience in ultrasound guided biopsies of organs and mass lesions. Again,
this experience can be extended to prostate biopsies.
Radiologists are trained to use color-Doppler in different organs and areas. This experience can be beneficial
for prostatic ultrasound to detect isoechoic hypervascular ‘lesions’ and to target biopsies at this areas.
Since US contrast agents are more generally used by radiologists, and since there are promising data on the
use of contrast agents in prostate ultrasonography, patients could benefit from radiologists experience to
perform contrast enhanced ultrasonography, to further improve lesion detection, lesion characterization, and
to target biopsies.
Radiologists and MRI
MRI and the diagnosis of prostatic carcinoma
Perhaps MR imaging of the prostate has become a greater challenge for radiologists. With the growing
awareness of prostate cancer and the tendency towards its earlier detection, probably more patients will be
referred for MRI-detection of prostatic carcinoma, in particular patients with repeatedly negative biopsies and
increased or increasing PSA.
Radiologists should know what can be expected from MRI (i.e. detection of peripheral zone lesions), and
what is state-of-the-art MR-examination of the prostate, including the performance of contrast-enhanced MRI
(i.e. dynamic contrast-enhanced MRI). Only a dedicated technique enables differentiation between benign
and malignant focal lesions in the peripheral zone. With optimized technique, MR may be indicated for
detection and characterization of carcinoma originating in the central gland.
In addition, with appropriate material, MR-guided biopsies of suspicious areas can be performed. It can be of
great advantage that the radiologist reading the MR, performs the biopsies TRUS-guided with the knowledge
of the results of the MR-study. This safes considerable MR-time.
MR-spectroscopy is another modality enabling lesion detection and characterization. This technique,
however, needs additional support of physicists to achieve reliable and reproducible data.
MRI and staging of prostatic carcinoma
Radiologists should guide the clinicians to proper indications and patient selection for MR-imaging for T- and
N-staging, including the use of USPIO’s for N-staging in selected patients.
MRI and radiation therapy and other types of local therapy
Radiologists should gain experience in the communication of MR-data (fused data of imaging, dynamic
contrast-enhanced studies and spectroscopy) to radiotherapists for dose calculation for external beam
radiotherapy, intensity modulated radiotherapy, and brachytherapy. Likewise, similar information can be
communicated to urologists to direct other types of therapy (cryotherapy, radio frequency ablation.
Radiologists and CT
Radiologists should outline indications for CT in men with histology proven prostate carcinoma (N-staging).
Radiologists and PET-CT
Radiologists should carefully follow the evolution of PET-CT for the detection and staging of prostatic
carcinoma. Preliminar data suggest that specific agents used for PET are likely to become the future CT-
‘contrast agents’.
86

ASSESSMENT OF LOCAL EXTENSION OF PROSTATE CANCER BY TRUS
AND TRUS-GUIDED BIOPSY
François Cornud
Service de Radiologie, Hôpital Cochin, 27 rue du Faubourg St Jacques, 75014.
Several parameters are used to detect or predict occult extraprostatic spread of clinically confined prostate
cancer. The poor accuracy of rectal examination can be substantially improved by two means. The first is
TRUS-guided biopsies of the extraprostatic fat and/or the seminal vesicles in selected cases of clinically
localized palpable tumor. The second is a combined use of rectal examination, Gleason score and PSA level
to establish a mathematical model (nomograms or Partin Tables (1)) which can classify patients in low,
intermediate and high-risk groups for extraprostatic spread. Moreover, the measurement of the amount of
cancer tissue present in biopsy cores, assessed by the calculation of the number of sextants involved by
tumor (2) and/or the length of tumor tissue (3), has been added to better assess the risk of pT3 stage,
particularly in patients of the intermediate-risk group in the tables of Partin.
TRUS signs of extensive T3 stage tumors are visible in large volume tumors (≥ stage T2b-c, i.e involving
at least an entire lobe or both lobes),
The prostatic contour is markedly irregular, or the tumor is visible within the periprostatic fat, often at the level
of the posterolateral neurovascular bundles at the prostatic apex or base. When ECE is visible across the
posterior aspect of the prostate, the tumor is generally a clinical stage T3. Extensive signs of ECE are
observed in a minority of cases in patients with a newly diagnosed prostate cancer, owing to the fact that
most cancers are diagnosed, since the PSA era, at an earlier stage.
TRUS extensive or direct signs of SVI are very rarely observed. The seminal vesicles are enlarged and have
an altered echotexture. Direct tumor growth through a dilated SV is often observed in cases where stage T3b
was clinically suspected.
TRUS signs of presumptive T3 stage tumors.
Presumptive or indirect signs of ECE. A broad contact (> 23 mm) between the tumor and the prostate
contour is a represents a presumption sign of ECE which indicates biopsy of the periprostatic fat. This policy
should be extended to any focal bulging of the prostate contour by a visible or palpable hypoechoic lesion.
However, the bulging can be subtle and should be thoroughly searched to perform one or several biopsies of
the extraprostatic spaces. Lee et al. (4) highlighted the value of sampling the periapical fat around the
neurovascular bundles to detect occult ECE and Ravery et al. (5) showed that the specificity of the technique
was 100%. Endorectal MRI contributes to the prognostication of these biopsy stage T3 tumors. In our
experience (unpublished data), approximately half these tumors show no ECE on endorectal MRI. The
prognosis of these forms is better, as it has been reported that MRI T2 stage tumors show established
pathological ECE in no more than 15% of cases (6), compared to 94% of MRI T3 stage tumors (6).
Seminal vesicle invasion (SVI) is very rarely detected on TRUS without the contribution of TRUS-guided
biopsies of the seminal vesicles. Indications of SV biopsy depend strongly on TRUS findings. The first sign is
close contact between the nodule and the caudal junction of the seminal vesicle and the vas deferens (4, 7).
When the junction has a normal TRUS appearance, i.e. separated from the tumor by a strip of isoechoic
prostatic tissue, SVI is very unlikely (7). The second sign is visible in the parasagittal plane when the tumor
obscurs the prostato-seminal angle. This sign can indicate ECE followed by a direct invasion of the wall of
the ipsilateral seminal vesicle.
There are other reported factors predictive of a positive SV biopsy result. The positive biopsy rate of SV
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
Gleason score ≥7, the positive biopsy rate is 35-40% compared to 7% for patients with a lower grade (8). As
mentionned above, tumor location plays a key role and involvement of the prostate base on biopsies is
predictive of SVI (9). This approach requires second set of biopsies which can be avoided if presumptive
signs of SVI are detected at the time of the first set of biopsies.
87

Sextant biopsies and extraprostatic spread. A different approach for staging a newly diagnosed prostate
cancer is to combine the results of rectal examination, PSA level and Gleason score which are then
integrated in nomograms (10) which give a statistical risk of extraprostatic spread. The main value of the
nomogram is to select patients at low risk (≤ 20%) and high risk (≥80%) of extraprostatic spread. However,
between these extremes, the risk of extraprostatic spread ranges from 25 to 72% and the nomogram does
not offer enough accuracy to choose a therapeutic option, as underlined by D'Amico et al.(2). The nomogram
carries a risk of pitfalls at each clinical stage (1). To improve accuracy of nomograms, it has been proposed
to indirectly estimate tumor volume by two means: the first is to calculate the number of sextants involved on
biopsies and the second is to measure the length of cancer tissue on biopsy cores.
Numerous reports have confirmed that the number of involved sextants is a powerful independent prognostic
factor – even more powerful than the PSA level and the Gleason score. In patients with three or more
involved sextants the risk of postoperative failure (i.e. pT3 stage, positive margins or biological progression
after radical prostatectomy) is at least 45% (2, 5, 11-18). The number of positive biopsy specimens can also
be used to identify patients with a risk of extensive (i.e. established) pT3 tumors, who have a poor outcome
after surgery(19, 20). The percentage of extensive pT3 tumors is only 7% among patients with one or two
invaded sextants and almost five times higher (33%) when the number of involved sextants reaches three
(6). These findings have important implications with regard to the indications for endorectal MRI, which can
depict only extensive pT3 tumors (6).
The amount of cancer in biopsy cores. Three measurements are performed (21), namely the total length of
cancer (sum in mm of cancer present on all the cores), the maximum length observed on one core, and
percentage of cancer tissue (ratio of the sum in mm of cancer tissue on all biopsies to the total length of the
samples). Some studies have concluded that measurement of the amount of cancer more accurately predict
pT3 stage than the number of involved sextants (22-26), but others have found no such difference (27, 28).
As quantitative measurement of tumor and core length represents substantial work for the pathologist, further
studies are needed before recommending routine use of this method.
Conclusion
Local staging by TRUS-guided biopsy of the periprostatic spaces or seminal vesicles are strongly
recommended when indirect signs of T3a or T3b disease are detected by TRUS, which is only observed in
case of large tumors that are visible by TRUS and clinically palpable in most cases. When this direct staging
is not possible, the risk of extraprostatic disease can be estimated by counting the number of sextants
involved by the tumor and/or by measuring the mm of cancer tissue in biopsy cores (the latter method is still
under evaluation). This "quantitative histology" represents an excellent tool for selecting patients at
intermediate or high risk of extraprostatic spread, who need further imaging investigations (i.e endorectal
MRI) to detect an established occult extraprostatic spread.
References
1. Partin AW, Mangold LA, Lamm DM, Walsh PC, Epstein JI, Pearson JD. Contemporary update of prostate cancer staging nomograms
(Partin Tables) for the new millennium. Urology 2001;58(6):843-8.
2. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Schnall M, Tomaszewski JE, et al. Role of percent positive biopsies and
endorectal coil MRI in predicting prognosis in intermediate-risk prostate cancer patients. Cancer J Sci Am 1996;2(6):343-350.
3. Freedland SJ, Aronson WJ, Terris MK, Kane CJ, Amling CL, Dorey F, et al. Percent of prostate needle biopsy cores with cancer is
significant independent predictor of prostate specific antigen recurrence following radical prostatectomy: results from SEARCH
database. J Urol 2003;169(6):2136-41.
4. Lee F, Torp-Pedersen ST, Siders DB, Littrup PJ, McLeary RD. Transrectal ultrasound in the diagnosis and staging of prostatic
carcinoma. Radiology 1989;170(3 Pt 1):609-15.
5. Ravery V, Boccon-Gibod LA, Dauge-Geffroy MC, Billebaud T, Delmas V, Meulemans A, et al. Systematic biopsies accurately predict
extracapsular extension of prostate cancer and persistent/recurrent detectable PSA after radical prostatectomy. Urology
1994;44(3):371-6.
6. Cornud F, Flam T, Chauveinc L, Hamida K, Chretien Y, Vieillefond A, et al. Extraprostatic spread of clinically localized prostate cancer:
factors predictive of pT3 tumor and of positive endorectal MR imaging examination results. Radiology 2002;224(1):203-10.
7. Cornud F, Belin X, Fromont G, Chretien Y, Helenon O, Boisrond L, et al. [What may be expected from endorectal ultrasonography and
magnetic resonance imaging in the assessment of local extension of cancer of the prostate?]. J Urol 1991;97(4-5):179-88.
8. Stock RG, Stone NN, Ianuzzi C, Unger P. Seminal vesicle biopsy and laparoscopic pelvic lymph node dissection: implications for
patient selection in the radiotherapeutic management of prostate cancer. Int J Radiat Oncol Biol Phys 1995;33(4):815-21.
9. Guillonneau B, Debras B, Veillon B, Bougaran J, Chambon E, Vallancien G. Indications for preoperative seminal vesicle biopsies in
staging of clinically localized prostatic cancer. Eur Urol 1997;32(2):160-5.
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10. Partin AW, Kattan MW, Subong EN, Walsh PC, Wojno KJ, Oesterling JE, et al. Combination of prostate-specific antigen, clinical stage,
and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update [see comments] [published
erratum appears in JAMA 1997 Jul 9;278(2):118]. Jama 1997;277(18):1445-51.
11. Badalament RA, Miller MC, Peller PA, Young DC, Bahn DK, Kochie P, et al. An algorithm for predicting nonorgan confined prostate
cancer using the results obtained from sextant core biopsies with prostate specific antigen level. J Urol 1996;156(4):1375-80.
12. Borirakchanyavat S, Bhargava V, Shinohara K, Toke A, Carroll PR, Presti JC, Jr. Systematic sextant biopsies in the prediction of
extracapsular extension at radical prostatectomy. Urology 1997;50(3):373-8.
13. Egawa S, Suyama K, Matsumoto K, Satoh T, Uchida T, Kuwao S, et al. Improved predictability of extracapsular extension and seminal
vesicle involvement based on clinical and biopsy findings in prostate cancer in Japanese men. Urology 1998;52(3):433-40.
14. Narayan P, Gajendran V, Taylor SP, Tewari A, Presti JC, Jr., Leidich R, et al. The role of transrectal ultrasound-guided biopsy-based
staging, preoperative serum prostate-specific antigen, and biopsy Gleason score in prediction of final pathologic diagnosis in prostate
cancer. Urology 1995;46(2):205-12.
15. Peller PA, Young DC, Marmaduke DP, Marsh WL, Badalament RA. Sextant prostate biopsies. A histopathologic correlation with radical
prostatectomy specimens. Cancer 1995;75(2):530-8.
16. Wills ML, Sauvageot J, Partin AW, Gurganus R, Epstein JI. Ability of sextant biopsies to predict radical prostatectomy stage. Urology
1998;51(5):759-64.
17. D'Amico AV, Whittington R, Malkowicz SB, Schultz D, Fondurulia J, Chen MH, et al. Clinical utility of the percentage of positive prostate
biopsies in defining biochemical outcome after radical prostatectomy for patients with clinically localized prostate cancer [see
comments]. J Clin Oncol 2000;18(6):1164-72.
18. Huland H, Hammerer P, Henke RP, Huland E. Preoperative prediction of tumor heterogeneity and recurrence after radical
prostatectomy for localized prostatic carcinoma with digital rectal, examination prostate specific antigen and the results of 6 systematic
biopsies. J Urol 1996;155(4):1344-7.
19. Partin AW, Borland RN, Epstein JI, Brendler CB. Influence of wide excision of the neurovascular bundle(s) on prognosis in men with
clinically localized prostate cancer with established capsular penetration. J Urol 1993;150(1):142-6; discussion 146-8.
20. Ohori M, Scardino PT, Lapin SL, Seale-Hawkins C, Link J, Wheeler TM. The mechanisms and prognostic significance of seminal
vesicle involvement by prostate cancer. Am J Surg Pathol 1993;17(12):1252-61.
21. Bismar TA, Lewis JS, Jr., Vollmer RT, Humphrey PA. Multiple measures of carcinoma extent versus perineural invasion in prostate
needle biopsy tissue in prediction of pathologic stage in a screening population. Am J Surg Pathol 2003;27(4):432-40.
22. Egan AJ, Bostwick DG. Prediction of extraprostatic extension of prostate cancer based on needle biopsy findings: perineural invasion
lacks significance on multivariate analysis. Am J Surg Pathol 1997;21(12):1496-500.
23. Ravery V, Chastang C, Toublanc M, Boccon-Gibod L, Delmas V. Percentage of cancer on biopsy cores accurately predicts
extracapsular extension and biochemical relapse after radical prostatectomy for T1-T2 prostate cancer. Eur Urol 2000;37(4):449-55.
24. Freedland SJ, Csathy GS, Dorey F, Aronson WJ. Percent prostate needle biopsy tissue with cancer is more predictive of biochemical
failure or adverse pathology after radical prostatectomy than prostate specific antigen or Gleason score. J Urol 2002;167(2 Pt 1):516-
20.
25. Freedland SJ, Aronson WJ, Csathy GS, Kane CJ, Amling CL, Presti JC, Jr., et al. Comparison of percentage of total prostate needle
biopsy tissue with cancer to percentage of cores with cancer for predicting PSA recurrence after radical prostatectomy: results from the
SEARCH database. Urology 2003;61(4):742-7.
26. Naya Y, Slaton JW, Troncoso P, Okihara K, Babaian RJ. Tumor length and location of cancer on biopsy predict for side specific
extraprostatic cancer extension. J Urol 2004;171(3):1093-7.
27. Sebo TJ, Bock BJ, Cheville JC, Lohse C, Wollan P, Zincke H. The percent of cores positive for cancer in prostate needle biopsy
specimens is strongly predictive of tumor stage and volume at radical prostatectomy [see comments]. J Urol 2000;163(1):174-8.
28. Linson PW, Lee AK, Doytchinova T, Chen MH, Weinstein MH, Richie JP, et al. Percentage of core lengths involved with prostate cancer
does it add to the percentage of positive prostate biopsies in predicting postoperative prostate-specific antigen outcome for men with
intermediate-risk prostate cancer? Urology 2002;59(5):704-8.
WHAT TO DO WITH SUSPICIOUS ADENEXAL MASS AT US?
Kaori Togashi
Kyoto university
INTRODUCTION
Ovarian cancer is the second most common gynecologic malignancy, but has the highest mortality rate of all
of the gynecologic malignancies with an overall 5-year survival rate of 46% [1]. In spite of diagnostic and
therapeutic advances in the care of women with ovarian cancer, the overall 5-year survival rate has changed
little [1, 2]. The major reason for this poor prognosis is that roughly 75% of patients have diseases at an
advanced stage [1, 2]. Early detection with accurate staging is of paramount importance to improve
prognosis. This presentation briefly discusses the clinical roles of imaging studies, including computed
tomography (CT) and magnetic resonance (MR) imaging, and Posittron computed Tomogrraphy (PET) in the
course of diagnosis, staging, and treatment of suspicious adnexal masses at US.
The role of IMAGING EVALUATION OF SUSPICIOUS ADNEXAL MASSES AT US
For uncertain or problematic cases at US to determine the degree of malignancy, follow up US, a serum CA-
125 level, and MR imaging narrow the differential diagnosis. In postmenopausal women, we should be
89

careful as levels exceeding 65 U/ml are predictive of malignancy in 75% of women with pelvic masses,
although in premenopausal women with more than 90% of findings being false-positive[3]. MR imaging
helps to distinguish benign from malignant, with an overall accuracy for the diagnosis of malignancy of 93 %.
The MR findings most predictive of malignancy are vegetation in a cystic tumor and necrosis in a solid tumor
[4] . Dissemination and adenopathy should also be carefully evaluated, as they can be a strong indicator of
malignancy. MR imaging is frequently helpful in the further characterization of adnexal masses. The
accuracy of MR imaging in the confident diagnosis of mature cystic teratoma, endometrial cysts, and
leiomayomas is very high. CT is not indicated for differential diagnosis of adnexal masses because of poor
soft tissue discrimination, except for fatty tissue and for calcification, and the disadvantages of irradiation.
PET is not indicated to determine the degree of malignancy [5].
If MR imaging confirms a dermoid or endometrial cyst, further diagnostic procedures are unnecessary [5]. If
MR findings allow the unequivocal diagnosis of a dermoid or endometrial cyst, laparoscopy will safely be
referred [5]. In all other cases, surgical evaluation should be considered at the time, and an intraoperative
frozen section is the golden standard for patients with ovarian tumors. Patients with advaced stage ovarian
cancer experience a significant survival advantage when a gynecologic oncologist is involved in their
treatment [6]. However, unfortunately, gynecologic oncologists see less than half of ovarian cancer patients
at present [6]. Whatever the modality used, imaging studies is important in the determination of the
appropriate referral to gynecololgic oncologists, and thus to obtain a longer survival [7].
STAGING
The majority of ovarian cancers present as advanced stage III-IV. The role of imaging in staging ovarian
cancer has been considered to be of limited use previously. However, surgical staging itself has an inherent
weakness. Even with a laparotomy, the detection of all tumors is not feasible; up to 50% of patients who
have a negative second-look surgery result eventually develop a recurrent tumor [8,9]. An accurate
preoperative depiction of possible sites of dissemination with imaging studies is mandatory for determining
the sites for biopsy during surgery, in addition to referring the patient with an advanced stage of the disease
to a cancer center [10].
CT has been demonstrated to be reasonably accurate in determining which patients may have tumor
implants that can be optimally surgically debulked [11,12]. Excellent results are recently shown in CT and
contrast-enhanced MR imaging in delineating small peritoneal diseases, with sensitivities of 95% and 92%,
respectively [10]. Both modalities are equally accurate, and can be used to stage advanced ovarian cancer
[10]. The most common sites of peritoneal disease are the omentum, followed by subphrenic spaces, the
mesentery (large and small bowel), the anterior part of the abdomen, and the paracolic gutters [10]. US is
generally considered to be of limited use to help evaluate hepatic substances and the lymph nodes, however,
a large study has shown little difference between US, CT, and MRI in the staging of ovarian cancer with the
highest specificity of 96% and the lowest sensitivity of 75% for US [7]. If an abdominal spread is detected
with US, the accuracy of a diagnosis of a stage III disease is high. Because of the importance of not
understaging the abdominal malignancy as a disease limited to the pelvis, if stage III cancer is not detected
at the initial abdominal US, CT or MR, imaging should be performed because of their higher sensitivities in
staging [7]. The role of PET in staging ovarian cancer is still under debate. Several studies have shown its
value in the evaluation of recurrent ovarian tumor, however the data is limited for fresh ovarian tumors [13] .
Larger study will be necessary to conclude the role of PET or CT-PET in staging ovarian cancer.
CONCLUSION
Although it is difficult to suggest a simple strategy for evaluating the state of women with adnexal masses,
the correct preoperative diagnosis of ovarian cancer with the use of any of imaging studies will lead to an
appropriate referral to a specialist in gynecologic oncology and offer a significant survival advantage for
patients with ovarian cancer.
References
1. American Cancer Society (1998) Cancer facts and figures: 1998. American Cancer Society 13
2. Pecorelli S (1998) FIGO annual report on the results of treatment in gynaecological cancer, volume 23. J Epidemiol Biostatistics 3: 1-
135
3. Bohm-Velez M, Mendelson E, Bree R, Finberg H, Fishman EK, Hricak H, Laing F, Sartoris D, Thurmond A, Goldstein S (2000)
Ovarian cancer screening. American College of Radiology. ACR Appropriateness Criteria. Radiology 215 Suppl: 861-871
90

4. Hricak H, Chen M, Coakley FV, Kinkel K, Yu KK, Sica G, Bacchetti P, Powell CB (2000) Complex adnexal masses: detection and
characterization with MR imaging-- multivariate analysis. Radiology 214: 39-46
5. Rieber A, Nussle K, Stohr I, Grab D, Fenchel S, Kreienberg R, Reske SN, Brambs HJ (2001) Preoperative diagnosis of ovarian tumors
with MR imaging: comparison with transvaginal sonography, positron emission tomography, and histologic findings. Am J Roentgenol
177: 123-129
6. Carney ME, Lancaster JM, Ford C, Tsodikov A, Wiggins CL (2002) A population-based study of patterns of care for ovarian cancer:
who is seen by a gynecologic oncologist and who is not? Gynecol Oncol 84: 36-42
7. Kurtz AB, Tsimikas JV, Tempany CM, Hamper UM, Arger PH, Bree RL, Wechsler RJ, Francis IR, Kuhlman JE, Siegelman ES, Mitchell
DG, Silverman SG, Brown DL, Sheth S, Coleman BG, Ellis JH, Kurman RJ, Caudry DJ, McNeil BJ (1999) Diagnosis and staging of
ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic
analysis--report of the Radiology Diagnostic Oncology Group. Radiology 212:19-27
8. Friedman JB, Weiss NS (1990) Second thoughts about second-look laparotomy in advanced ovarian cancer. N Engl J Med 322: 1079-
1082
9. Podratz KC, Malkasian GD, Jr., Wieand HS, Cha SS, Lee RA, Stanhope CR, Williams TJ (1988) Recurrent disease after negative
second-look laparotomy in stages III and IV ovarian carcinoma. Gynecol Oncol 29: 274-282
10. Tempany CM, Zou KH, Silverman SG, Brown DL, Kurtz AB, McNeil BJ (2000) Staging of advanced ovarian cancer: comparison of
imaging modalities-- report from the Radiological Diagnostic Oncology Group. Radiology 215: 761-767
11. Forstner R, Hricak H, Occhipinti KA, Powell CB, Frankel SD, Stern JL (1995) Ovarian cancer: staging with CT and MR imaging.
Radiology 197:619-26
12. Meyer JI, Kennedy AW, Friedman R, Ayoub A, Zepp RC (1995) Ovarian carcinoma: value of CT in predicting success of debulking
surgery. Am J Roentgenol 165:875-8
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
positron emission tomography with FDG for recurrent ovarian cancer. Am J Roentgenol 176: 1449-1454
IMAGING OF ENDOMETRIAL CANCER: THE YORKSHIRE CANCER
NETWORK GUIDELINES
Sarah E Swift, Michael J Weston and John A Spencer
Consultant Radiologists, The Leeds Cancer Centre at St James’s University Hospital, Leeds LS9 7TF, UK
Endometrial cancer is a disease of older women. Less than 5% of cases occur in premenopausal women. It
has similar incidence to ovarian and cervical cancer but much lower mortality as most women present with
early stage disease (appendices 1, 2) since unexpected vaginal bleeding is a worrying symptom. Prompt
assessment is required to distinguish those women with cancer from those with other benign, senile and
atrophic pathologies. In this brief review we describe our practical approach to imaging of endometrial
cancer.
The main role of ultrasound (US), in women suspected of having endometrial cancer, is to identify those who
do not require hysteroscopy and guided biopsy. There is also no role for ultrasound in women who will
undergo hysteroscopy and biopsy irrespective of the findings of US.
Primary indications for ultrasound or hysteroscopy
• Post-menopausal bleeding (PMB): bleeding after six months amenorrhoea is the cardinal symptom of
endometrial cancer
• Persistent unexpected bleeding with hormone replacement therapy
• Persistent unexplained vaginal discharge in a postmenopausal woman
• Pre-menopausal bleeding: persistent or heavy intermenstrual bleeding, symptoms which demand
consideration of cervical cancer
Women should attend with a full bladder. Before the scan the menstrual state should be recorded, as well as
any history of gynaecological surgery, IUCD and any medications such as Tamoxifen, HRT etc. If cyclical
HRT is being taken, the scan should be timed for the withdrawal bleed.
A transabdominal scan is done first. This is so that large masses that extend out of the pelvis, omental cake
or ascites are not overlooked. The kidneys should be examined looking primarily for hydronephrosis as an
integral part of any pelvic scan. A transvaginal scan is essential to assess the endometrium and requires the
bladder to be emptied. A transvaginal scan is a dynamic investigation in that the relative mobility of the
91

pelvic structures can be assessed. The free hand can also be used to press gently on the lower abdomen to
bring structures into view.
Minimum imaging protocol of the endometrium
• Uterus in longitudinal and transverse sections ( LS and TS)
• Endometrium in LS and TS
• Measure double layer thickness of endometrium in LS excluding any fluid
• Both ovaries and any other adnexal lesion
• Both kidneys
Detailed questions and extended protocol if abnormality found
• Is the endometrium uniformly or focally enlarged?
• Is the endometrium cystic or not?
• Is there any fluid in the endometrial cavity?
• Is the subendometrial darker halo intact?
• Are any submucosal fibroids or endometrial polyps identifiable?
• What is the relative width of endometrium compared to overall uterine width?
• Colour Doppler of the endometrium and uterine arteries
• A search for distant spread in abdomen
Criteria for assessment
A postmenopausal endometrial double layer thickness of 4mm or less effectively excludes endometrial
cancer and in these women hysteroscopy can usually be avoided.
Colour flow Doppler signal present within the postmenopausal endometrium raises the likelihood of cancer.
Low impedance flow (RI less than 0.5) and high peak systolic velocities (over 40cm/s) in a postmenopausal
fibroid raise the possibility of sarcomatous change.
Investigation after abnormal ultrasound
Hysteroscopy and guided biopsy are required for women with postmenopausal bleeding and a thickened
endometrium.
If hysteroscopy is not readily available, then saline infusion sonohysterography and pipelle biopsy may help
select those who need further intervention.
MRI can help with local spread but is not routinely indicated (see MR imaging protocol.
A chest radiograph (CXR) completes staging and as many women have co-morbidity may be required as
part of the anaesthetic assessment.
Multidisciplinary discussion between specialist gynaecological surgeons, oncologists, pathologists and
radiologists is central to defining treatment options and usually follows staging examinations but may occur
earlier if there are problems such as co-morbidity which limit investigation and treatment options. It is
particularly important that women with high grade disease (G3) and pathologies other than endometrial
cancer e.g. papillary serous, small cell and clear cell carcinoma or sarcoma are assessed in cancer centres.
It is unclear whether all women with endometrial cancer require staging with MR imaging.
Indications for MR imaging with proven or suspected endometrial cancer
• Histologically high grade (G3) tumour
• Suspicion for advanced disease, especially cervical involvement
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• Patients who represent a poor operative risk and will not undergo surgical staging
• Inability to properly assess the endometrium hysterocopically e.g with cervical stenosis
Surgical management of endometrial cancer may be influenced by the findings of MR imaging in two
situations. Deep myometrial invasion (stage IC) and high grade tumour increase the risk of nodal
metastases. These patients require nodal dissection for adequate surgical staging. Involvement of the
cervical stroma (stage 2B) indicates the need for radical hysterectomy.
Technique for MR imaging of endometrial cancer
• Avoid vaginal tampon
• Intravenous anti-peristaltic agent – Glucagon or Buscopan
• Phased array pelvic coils
• Sagittal SFOV (20 cm) T2W sequence through the pelvis
• ‘Inclined axial’ SFOV T2W sequence perpendicular to the endometrial cavity
• 3 or 4mm sections with SFOV, ideally 512 matrix size
• LFOV axial FISP and coronal T1W sequences through the retroperitoneum and pelvis to assess nodal
disease and hydronephrosis
• Supervision of the examination by radiologist experienced in gynaecological MR
Invasive endometrial carcinoma disrupts the low SI junctional zone (JZ) on the T2W sequences, extending
for a variable depth into the myometrium. Invasion of the JZ in dicates stage 1B and of the outer half of the
myometrium as stage 1C. The JZ may be indistinct in post-menopausal women and in this group dynamic
gadolinium enhanced T1W sagittal and ‘inclined’ axial SFOV images are helpful in defining tumour and
assessing depth of invasion. Fat suppressed gradient echo sequences are used. With this technique the
tumour is hypointense, less vascular, than myometrium and there is a sub-endometrial enhancement (SEE)
which defines the tumour margin.
The key role of staging is to define women with deep muscle invasion from superficial disease, those with
cervical invasion and with locally advanced disease. MR imaging is best at assessment of myometrial
invasion and cervical invasion but still relatively insensitive to nodal metastasis.
The role of CT in Endometrial Carcinoma
Where MRI is available there is no role for CT in initial staging. CT is inferior to both US and MR imaging for
early stage disease assessment but has value in other circumstances. With known advanced disease, CT is
the modality of choice to provide information about disease beyond the pelvis, assessment of the thorax and
upper abdomen, identification of marker lesions. CT is used in many centres for radiotherapy planning and
also for treatment assessment in women receiving chemotherapy for advanced or recurrent disease.
Appendix 1: FIGO Staging – Carcinoma of the Corpus Uteri
Carcinoma of the corpus uteri: Pathological staging FIGO nomenclature (Rio de Janeiro 1994)
Stage Ia
Stage Ib
Stage Ic
Stage IIa
Stage Iib
Stage IIIa
Stage IIIb
Stage IIIc
Stage IVa
Stage IVb
Tumour limited to the endometrium.
Invasion to less than half of the myometrium.
Invasion equal to or more than half the myometrium.
Endocervical glandular involvement only.
Cervical stromal invasion.
Tumour invades the serosa of the corpus uteri and/or adnexae and/or positive peritonial cytological
findings.
Vaginal metastases.
Metastases to pelvic and/or paraaortic lymph nodes.
Tumour invasion of bladder and/or bowel mucosa.
Distant mestastases, including intra-abdominal metastasis and/or inguinal lymph nodes.
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Appendix 2: Stage grouping for endometrial cancer, FIGO cf UICC
FIGO
UICC
Stage T N M
0 Tis N0 M0
Ia T1a N0 M0
Ib T1b N0 M0
Ic T1c N0 M0
Iia T2a N0 M0
IIb T2b N0 M0
IIIa T3a N0 M0
IIIb T3b N0 M0
IIIc T1 N1 M0
T2 N1 M0
T3a N1 M0
T3b N1 M0
Iva T4 Any N M0
IVb Any T Any N M1
KEY REFERENCES
US in diagnosis
Gull B et al. Am J Obstet Gynecol 2003; 188: 401-408.
Gupta JK et al. Acta Obstet Gynecol Scand 2002; 81: 799-816.
MR in staging
Kinkel K et al. Radiology 1999; 212: 711-718.
Frei KA et al. Radiology 2000; 216: 444-449.
Manfredi R et al. Radiology. 2004; 231:372-378.
PEDIATRIC UROLOGIC EMERGENCIES: IMAGING IN ACUTE URO-GENITAL
TRAUMA, TESTICULAR AND OVARIAN TORSION
Riccabona Michael
Department of Radiology, Division of Pediatric Radiology
University Hospital Graz, Austria
Abstract
Basic imaging strategies in pediatric urogenital trauma resemble the common algorithms in adults - however,
there are differences injury patterns and risks that impact imaging strategies. The objective of this
presentation is to basically list, explain, and discuss these differences.
When one thinks about imaging there are some basic aspects that have to be considered: what are the
information we need to decide on patient handling, therapy and prognosis, and which imaging modality or
algorithm can reliably provide this at lowest achievable patient burden within the time span necessary for
decision making. Additionally we have to consider availability of the various methods and economic aspects.
Eventually only evidence based and efficacy oriented algorithms will prove valid and acceptable. Therefore -
when discussing pediatric urogenital trauma - we must focus on scenarios with a significant risk for an injury
that need urgent treatment or close monitoring to achieve optimal results or to improve outcome. And we
have to reflect the specific aspects of children needs: the task to use non-ionising imaging modalities when
ever possible (ALARA principle), the specific pediatric circulation physiology and topographic anatomy, the
problems with communication and history, and the different trauma mechanisms with their consequences on
the type of a potential injury.
There are some basic facts: children stay stable for a long time even in severe injury and may suddenly
deteriorate dramatically; the kidneys are much more mobile than in adults and far less protected which
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increases the risk for particularly hilar injuries; the child’s bladder is positioned much higher, with a larger
peritoneal surface increasing the risk for intraperitoneal bladder rupture. Child abuse is another topic on the
list. Ovarian torsion in prepubertal girls is often associated with an underlying condition (tumor, infiltration),
and testicular torsion in neonates differs from the “adult” torsion mechanism (intra- versus extratesticular).
And – due to the different imaging conditions in infancy and childhood – imaging approaches differ: US as a
non-ionizing, but - in infants and children - highly sufficient imaging tool is used much more, whereas CT is
used more reluctantly in certain settings.
In conclusion this presentation shall try to demonstrate typical pediatric urogenital tract trauma settings and
conditions, show some typical findings, and suggest imaging algorithms for common clinical queries.
IMAGING IN ACUTE PEDIATRIC URINARY TRACT INFECTIONS
Prof. Kassa Darge
Department of Pediatric Radiology, Institute of Radiodiagnostic, University Hospital Wuerzburg, Josef-
Schneider-Str. 2/D31, 97080 Wuerzburg, Germany
[darge@roentgen.uni-wuerzburg.de]
Urinary tract infections (UTI) are the most common serious bacterial infections in infants and young children.
They are even more common than bacterial pneumonia. By the age of 7 years about 8% of girls and 2% of
boys would have had at least one episode of UTI. The UTI may be limited to the bladder, one or both
kidneys, or both sites. In general, infections of the bladder i.e. cystitis, although they cause substantial
morbidity, are not regarded as serious bacterial infections. In contrary, infections that involve the kidney,
namely pyelonephritis may cause both acute morbidity and lead to scarring with the consequences of
hypertension, preeclampsia and chronic renal disease that may necessitate dialysis or renal transplantation.
Accordingly, differentiation of site of infection has received considerable attention.
Urinalysis is very useful for detecting infection but not for determining the location of the infection within the
urinary tract – upper tract vs. lower tract. To determine the site of infection – kidney vs. bladder – attempts
are made to use the discriminatory ability of C-reactive protein (CRP), erythrocyte sedimentation rate, total
peripheral WBC and more recently serum procalcitonin (PCT). Imaging studies also play an important role in
this regard.
The aim of this presentation is to discuss in detail the use of US in the initial evaluation of a pediatric patient
presenting with UTI. Other imaging studies are usually not performed in the acute stage and will only be
handled briefly. The questions to be answered by the first US examination are the following:
1. Is there renal parenchymal involvement?
2. Is there accompanying obstruction that requires immediate surgical intervention?
3. Are there morphological peculiarities or abnormalities of the urinary tract?
A systematic performance of the US examination will make it possible to pick up all important findings:
[a] Bladder:
It is essential to start the US examination with the bladder so as not to miss the opportunity to examine the
bladder while it is full. Particularly, infants and small children may void when undressed and exposed to a
cold surrounding or irritated by the whole examination. An empty bladder may render the evaluation of the
bladder content, the terminal ureters and the status of the renal pelvis incomplete. It is important to note
whether floating echoes are present which may indicate purulent content. The bladder wall thickness should
not exceed 3 mm when full and 5 mm when empty. Any bladder wall irregularities should be noted. It is
helpful to note the volume of urine in order to compare with the amount of residual urine after voiding.
Residual urine may be indicative of accompanying bladder emptying disorder.
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[b] Ureters:
Both vesicoureteral junctions are assessed for the presence of abnormalities like ureterocele or ectopia.
Extent and form of dilatation of the ureters and presence of ureteral wall thickening are evaluated. The
echogenicity of the ureteral content should be noted, too.
[c.] Kidneys:
The examination of the kidneys should be carried out form ventral and dorsal. A meticulous evaluation of the
echogenicity of the kidneys with respect to the liver and spleen is necessary. Normally, the right and left
kidneys are hyperechoic compared to the liver and spleen, respectively, except in newborns and infants in
whom they can still be hyper- or isoechogenic. The presence and extent of the cortico-medullary
differentiation is assessed. The measurement of the renal size i.e. renal length and /or volume is very
important. A size increase above the norm for the height or weight of the patient or a volume difference of
more than 30% between the two kidneys may indicate the involvement of the renal parenchyma. The
pelvicalyceal system is assessed for the presence of dilatation, pelvic wall thickening and echogenic content.
The thickness of the normal pelvic wall should not exceed 0.8 mm. Furthermore, a thorough color or power
Doppler appraisal of the renal parenchyma may point out areas with decreased or absent perfusion due to
edema and inflammation.
Further diagnostic imaging studies for UTI are performed at the end of the antibiotic therapy for
pyelonephritis or even later. The aims of these imaging studies are twofold, namely to find out if
vesicoureteral reflux or renal scars are present. Reflux examination entails the use of one of the following
methods: contrast-enhanced voiding urosonography (VUS), voiding cystourethrography (VCUG) or direct or
indirect radionuclide cystography. The assessment for possible renal scars is carried out using DMSA scan.
MALIGNANT ADRENAL MASSES
Gabriel P. Krestin, M.D., Ph.D.
Department of Radiology, Erasmus MC, University Medical Center Rotterdam
PO Box 2040, Rotterdam, Netherlands 3000 CA
e-mail: g.p.krestin@erasmusmc.nl
Introduction
Adrenal masses are seen at autopsy in 2-10% of all patients and metastases are found postmortem in the
adrenal glands in up to 26% of patients with primary extra-adrenal malignancies. It is thus not surprising that
adrenal mass lesions are quite common incidental findings during imaging of the abdomen. However, even
in an oncologic setting, many adrenal lesions are benign, mostly non-hyperfunctioning adenomas, resulting
in the need of a reliable method to distinguish them from malignant masses.
Currently computed tomography (CT) and magnetic resonance imaging (MRI) are used in the evaluation of
the adrenal glands. The role of ultrasound (US) in assessment of adrenal pathologies is limited. Although it
can delineate most masses exceeding 2 cm, bowel gas may hamper depiction of the left adrenal gland and
distinction between benign and malignant lesions is impossible in most cases. Radionuclide scanning can
provide additional functional information in specific cases. Computed tomography is very sensitive in the
detection of adrenal pathologies, but lacks tissue specificity except for uncomplicated cysts and most
myelolipomas. Magnetic resonance imaging has been shown to be superior to CT in this respect.
Imaging Strategies in Adrenal Masses
Computed Tomography
High resolution CT is currently the gold standard for the detection of adrenal pathology. Contiguous slices of
10 mm thickness are adequate for routine scanning. Thinner sections are recommended for specific adrenal
imaging using 3-5 mm contiguous or overlapping scans. Spiral CT may assess the glands in one single
breath-hold. Spatial resolution may be improved if a small field of view is used. The raw scan data can be
retained for a subsequent target reconstruction.
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Oral contrast should be used in all cases to identify the gastrointestinal tract. Initial scans should be
performed without IV contrast medium to demonstrate calcifications or hemorrhage and to determine the
plain attenuation values of the adrenal glands. If these scans are abnormal or equivocal, IV contrast may be
used to define the contrast enhancement patterns of the lesion and to generate washout curves.
Magnetic Resonance Imaging
In most studies on MR imaging of the adrenal glands, axial T1-weighted and T2-weighted spin-echo
sequences with 7-10 mm section thickness were used. The use of a T2-weighted fast spin-echo sequence
instead of the conventional technique reduces acquisition time and thus motion artifacts resulting in better
image quality. Alternatively to the T2-weighted spin-echo sequences, a fast gradient-echo sequence with
relative T2-weighting (TR 60 ms/TE 30 ms/flip angle 15º) may be used. The technique has the advantage of
shortened acquisition time. This allows for slice by slice imaging during suspended respiration resulting in
improved image quality. A turbo gradient-echo sequence offers the possibility of imaging multiple slices
within a breath-hold of 18-25 seconds using a TR of 100 - 150 ms (depending on patients’ ability to hold their
breath), minimum TE (2 - 5 ms) and a flip angle 60 - 90°. Section thickness should range between 6 - 8 mm
with a 20% gap.
On these pulse sequences, the normal adrenal glands are iso- or hypointense compared to the liver. If fat
suppression is applied, the glands become isointense to the liver on T1-weighted and hyperintense on T2-
weighted images. Advantages of fat-saturation are reduced noise and sharper depiction of organ
architecture, reduced respiratory motion induced artifacts, elimination of chemical shift artifacts and
expanded gray scale to accentuate small differences in tissue contrast. Disadvantages include fewer
sections per acquisition and possible inhomogeneity of fat suppression throughout the image.
Adrenal adenomas and nodular hyperplasia contain large amounts of fat, whereas metastases and
pheochromocytomas contain no or very little lipid. Thus chemical shift imaging with in-phase and opposed
phase gradient echo images has been advocated to distinguish adenomas (fatty) from non-adenomatous
(non-fatty) lesions. On a 1.5 Tesla MR system (64 MHz), lipid and water spins have a frequency difference
of about 224 Hz. Thus, a phase cycling of water and lipid spins occurs with every 2.24 ms after the
excitation pulse. At this interval, lipid and water spins are alternately in- and out-of-phase. The signal
intensity of opposed phase images depends on the proportion of lipid and water content within the tissue.
Compared to non-lipid containing tissue, fat-containing tissue will thus present low signal intensity on
opposed phase images. Tsushima et al. propose FLASH (fast low-angle shot) images obtained breathheld
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
images with a flip angle of 20º. Mitchell et al. used a gradient recalled echo sequence (GRE) with 90º flipangle,
TR = 59-142 ms/TE = 2.3-2.5 ms for the opposed phase images.
Dynamic multiplanar fast gradient echo MR imaging with bolus injection during suspended respiration allows
for high image quality as well as visualization of functional processes after administration of contrast material.
It is reliable for demonstration and characterization of adrenal masses providing a statistically significant
differentiation of adenomas, metastases, and pheochromocytomas, although some overlap is still seen
between these pathologies. Dynamic MR imaging can be achieved by using a GRE sequence with a TR of
30 ms, a TE of 15 ms and a flip angle of 70º. Orientation in the coronal section allows for simultaneous
imaging of the adrenal glands, liver, and kidneys. Repeated imaging up to 15 minutes after intravenous
administration of 0.1 mmol/kg body weight of a gadolinium compound should be performed.
Presentation of Malignant Adrenal Lesions
Adrenal Metastases
Certain morphologic criteria are suggestive for a malignant adrenal lesion on CT or MRI, including diameter
over 5 cm, irregular contours, invasion of neighboring structures and change in size on follow-up
examinations. Adrenal metastases appear hypo- or isointense to liver on T1-weighted images and show a
strong signal increase on T2-weighted images. Comparing relative lesion-to-fat signal intensities, malignant
lesions usually present ratios of more than 2.0. Using these criteria, accuracies between 91% and 95% for
distinction between adenoma and adrenal metastases were found.
Following administration of contrast material, metastases show typically a rapid contrast-enhancement with a
maximum signal increase > 150% and a persistent high signal intensity (>75%) after 10 min.
97

On chemical shift opposed-phase images, metastases can be distinguished from the fat-containing
adenomas by their higher signal intensities. Tsushima et al. calculated signal intensity indexes between inphase
and opposed-phase images. In this study, using a cut-off value of 5%, a 100% accuracy in distinction
of adenomas from non-adenomatous lesions was found.
Metastases of renal cell carcinoma, hepatocellular carcinoma, and liposarcoma, however, may contain
cytoplasmic lipid and thus also present with a loss of signal intensity on opposed-phase images.
Adrenal Carcinoma
Fifteen to fifty percent of adrenocortical carcinomas are hyperfunctioning with the majority of them causing
Cushing's syndrome. They are usually larger than 6 cm in diameter and can invade adjacent organs and the
inferior vena cava. Calcifications may be present. With MRI, relaxation times of carcinomas are not
significantly different from those found in metastatic disease and distinction between these two entities can
thus not be made. However, primary adrenocortical carcinomas are usually unilateral and often hormonally
active. Due to its multiplanar imaging capabilities, MRI has been reported to be superior to CT in staging of
disease allowing better identification of invasion into adjacent structures.
Lymphoma
Non-Hodgkin’s lymphoma may rarely involve the adrenal glands. Contiguous growth from regional affected
lymph nodes into the adrenal glands is encountered more frequently, while isolated adrenal lymphoma
occurs only in exceptional cases. Bilateral involvement is seen in half of the cases. At imaging the enlarged
glands are indistinguishable from other malignant masses: The attenuation values at non-enhanced CT and
signal intensities on T2-weighted MR images are usually elevated and wash-out of the contrast agent is slow.
Suggested Readings
1. Elsayes KM, Mukundan G, Narra VR, Lewis JS, Shirkhoda A, Farooki A, Brown JJ. Adrenal masses: MR imaging features with
pathologic correlation. Radiographics 24:S73-S86, 2004
2. Dunnick NR, Korobkin M, Francis I (1996) Adrenal radiology: distinguishing benign from malignant adrenal masses. AJR 167:861-
867
3. Korobkin M (2000) CT characterization of adrenal masses: the time has come. Radiology 217:629-632
4. Korobkin M, Brodeur FJ, Francis IR, Quint LE, Dunnick NR, Londy F (1998) CT time-attenuation washout curves of adrenal adenomas
and nonadenomas. AJR 170:747-752
5. Lockhart ME, Smith JK, Kenney PJ. Imaging of adrenal masses. Eur J Radiology 41:95-112, 2002
6. Maurea S, Mainolfi C, Bazzicalupo L, Panico MR, Imparato C, Alfano B, Ziviello M, Salvatore M (1999) Imaging of adrenal tumors
using FDG PET: comparison of benign and malignant lesions. AJR 173:25-29
7. Peppercorn PD, Reznek RH. State-of-the-art CT and MRI of the adrenal gland. Eur Radiol 7:822-836, 1997
98

TECHNICAL PROTOCOLS FOR MALE AND FEMALE MRI OF THE
PELVIS
MAGNETIC RESONANCE EXAMINATIONS OF THE MALE PELVIS
Ullrich G. Mueller-Lisse, M.D.
Attending Radiologist, Associate Professor of Radiology, Dept. of Radiology,
University of Munich, Ziemssenstrasse 1, 80336 Muenchen, Germany,
e-mail: ullrich.mueller-lisse@med.uni-muenchen.de
Ulrike L. Mueller-Lisse, M.D.
Clinical Fellow, Dept. of Urology, University of Munich, Nussbaumstrasse 20
80336 Muenchen, Germany
Indications
Scanners and Coils
Sequences
Learning Objectives
Literature
Indications
Magnetic resonance (MR) examinations of the prostate and seminal vesicles primarily serve the purposes of
staging prostate cancer prior to therapy and of recognizing and localizing prostate cancer prior to biopsy and
after therapy. Other indications for MR examinations of the prostate, such as volumetric assessment of the
prostate prior to therapy for benign prostatic hyperplasia (BPH) or guidance and follow-up of alternative
therapies for prostatic disease, are rarely found outside of specialized centers.
MR examinations of the urinary bladder are primarily performed for staging of invasive bladder tumors and
for recognizing or ruling out other pelvic tumors that extend into the urinary bladder. Functional imaging of
the pelvic organs and pelvic floor by means of MR imaging is performed in cases of incontinence and relies
on repetitive imaging with high temporal resolution. Other indications, such as recognition or exclusion of
pelvic malformations in children, are rarely found outside of specialized paediatric centers. Virtual MR
cystoscopy is a new method under clinical investigation.
Scanners and Coils
MR examinations of the prostate and seminal vesicles and of the urinary bladder ought to be preformed on
whole-body high-field MR scanners. Recent series of MR examinations of the male pelvis that underwent
scientific evaluation were most frequently carried out at 1.5 T (e.g., Husband et al. 1989, Kim et al. 1994,
Barentsz et al. 1996). Initially, the body coil was used for both transmission and signal reception. Current coil
designs are based on multi-channel phased array technology with at least four independent coil elements.
Complex integration of the respective signals received by each of the coils results in homogenous MR
images with high signal-to-noise ratios. Recently, receiver coil systems with up to 32 independent channels
were introduced that allow for either more detailed MR images, i.e., increased spatial resolution without loss
of signal-to-noise, or for higher acquisition speed, particularly with so-called parallel imaging, i.e., the
application of knowledge of respective surface coil positions to the determination of magnetic resonance
signal origin as a means to decrease the number of phase encoding steps without losing spatial resolution in
a given sequence.
The application of endoluminal coils is of great advantage in MR examinations of the prostate and seminal
vesicles, particularly when the endoluminal coil is integrated into a multi-channel phased array coil system
(Hricak et al. 1994). Although butylscopolamine or glucagone can be used to decrease MR image
degradation by bowel motion when respective contraindications are considered, it is usually sufficient to fill
the inflatable balloon of the endorectal coil with 80-100 ccm of air once it has been placed in the emptied
rectum. Digital rectal examination should precede application of the endorectal coil, to rule out lesions and
narrowings in the rectum.
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Sequences
Pelvic anatomy is best depicted in T2-weighted MR sequences. Full delineation of the urinary bladder and of
the prostate and seminal vesicles requires acquisition of T2-weighted images in at least two different planes,
better even in three planes (axial, coronal, and sagittal). Slice thickness should not exceed 5-6 mm for MRI of
the urinary bladder, with interslice gaps not exceeding 1 mm. MR imaging of the prostate and seminal
vesicles requires very detailed depiction, such that slice thickness should not exceed 3-4 mm, and interslice
gap should be less than 0.6 mm. Axial images provide good overview of the urinary bladder and its
respective relation to the rectum, uterus, adnexae, vagina, or seminal vesicles and prostate, as well as its
separation from the iliac vessels and from the muscular and bony walls of the pelvis. Deviation from
symmetry between the two halves of the pelvis provides valuable clues to extent of prevalent disease. Axial
images with a field of view (FOV) with edges measuring up to 200 mm provide a good overview of the
prostate and its relation to the rectum, seminal vesicles, urinary bladder, urogenital diaphragm, the iliac
vessels, and the muscular and bony wall of the pelvis. Deviation from symmetry between the two halves of
the pelvis hints at disease.
T2-weighted spin-echo- (SE-) and turbo-SE- (TSE- or FSE-) MR images appear to delineate pathologic
changes in the wall of the urinary bladder equally well (Husband et al. 1989, Kim et al. 1994, Barentsz et al.
1996). Very fast, T2-weighted sequences, such as HASTE, SSFSE or True-FISP, have been available for
several years. These sequences have been successfully applied in the upper abdomen, upper urinary tract,
and retroperitoneum, with breathhold techniques decreasing motion artifact, and in functional MR imaging of
the pelvic organs and pelvic floor (Lienemann et al. 1997, Pannu et al. 2003). However, for MR imaging of
the urinary bladder, prostate, and seminal vesicles, equivalence of very fast sequences with SE and TSE
sequences has not been sufficiently demonstrated for the diagnosis of malignant disease.
T1-weighted, unenhanced SE- or FLASH- (spoiled GRE-) images with a slice thickness of 6-8 mm and an
interslice gap of 2 mm or less extend from the urogenital diaphragm to the aortic bifurcation and help to
recognize or rule out enlarged lymph nodes (particularly, along the obturator arteries, and the common,
external and internal iliac arteries and in the presacral space), potentially metastatic bone lesions, tumor
extending beyond the wall of the urinary bladder, and hemorrhage inside the prostate. Axial, T1-weighted SE
images with a slice thickness of 3 mm increase spatial resolution in the prostate.
Various studies have demonstrated that acquisition of rapid, T1-weighted MR images prior to, during, and
after intravenous administration of interstitial, gadolinium-based contrast media (often referred to as dynamic
contrast-enhanced MRI or DCE-MRI) at standard doses (e.g., 0.1 mmol of Gd-DTPA per kg of body weight)
is advantageous for the recognition and staging of tumors of the urinary bladder (Neuerburg et al. 1989,
Tachibana et al. 1991, Tanimoto et al. 1992, Kim et al. 1994, Barentsz et al. 1996). Single slice SE- or FSE
sequences (Tachibana et al. 1991, Tanimoto et al. 1992), gradient echo sequences (FLASH or GRE,
Neuerburg et al. 1989, Kim et al. 1994) as well as Turbo-FLASH sequences (Barentsz et al. 1996) have been
applied to DCE-MRI of the urinary bladder. The imaging plane for DCE-MRI is adapted to the respective
localization of the lesion in the urinary bladder, if the lesion was previously demonstrated in T2-weighted
images (Mueller-Lisse et al. 1998). In the prostate, DCE-MRI with subsequent calculation of signal alteration
characteristics, such as amplitude of contrast enhancement, or contrast exchange rates between the
bloodstream and interstitial space, is under clinical investigation. In particular, correlation between contrast
exchange rate and micro-vessel density in prostate tissue may provide new insight into biological tumor
aggressiveness, since poorly differentiated prostate cancer frequently shows with increased micro-vessel
density (Schlemmer et al. 2004). However, results have been demonstrated to depend on sequence
selection (Kiessling et al. 2003).
Organ-specific examinations include multi-dimensional MR spectroscopy (MRS) of the prostate. MRS is
based either on SE-sequences (PRESS, Bottomley 1987, Ordridge et al. 1985) or on STEAM-sequences
(Stimulated Echo Acquisition Mode, Frahm et al. 1987, Frahm et al. 1990) and analyzes the underlying
frequencies of the MR signal. Shimming (minimization of full width at half maximum of the water signal by
homogenization of the main magnetic field, B0) and suppression of signals from water and fat in the region of
interest by means of selective inversion pulses and outside the region of interest by means of selective prepulses
(outer volume suppression) gains access to signal contributions from metabolic products of lesser
tissue concentration, such as citrate, choline, and creatine. As a specialized biochemical function of the
prostate, citrate is accumulated rather than being entered into the citrate cycle of Krebs and broken down for
energy metabolism. Development of prostate cancer is associated with loss of citrate accumulation and
100

excretion. Free choline increases with increase of cell membrane turnover, such that it is more abundant in
the presence of cancer. Creatine is part of the energy storage systems of mammalian cells (Kurhanewicz et
al. 1995, Kurhanewicz et al. 1996, Costello et al. 1999, Heerschap et al. 1997, Scheidler et al. 1999, Mueller-
Lisse et al. 2001a+b, Mueller-Lisse and Scherr 2003).
Functional MR imaging of the urinary bladder and pelvic floor requires rapid, repetitive data acquisition by
means of T1-weighted (FLASH, Turbo-FLASH, Gupta et al. 1992, Nolte-Ernsting et al. 1998) or T2-weighted
(HASTE, True-FISP) sequences. Temporal resolution of 1 second or less is favorable (Lienemann et al.
1997, Pannu et al. 2003). Virtual cystoscopy can be based on three-dimensional, T2-weighted TSE images
(Lämmle et al. 2002).
Learning Objectives
- to get to know standard MR examination techniques and strategies in the diagnosis of diseases of the
male pelvis by means of selected case studies
- to get to know special MR examinations in the pelvis by means of selected case studies
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Zweikompartimentenmodells. Radiologe 43: 474—480
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Kurhanewicz J (2001a) Time-dependent effects of hormone-deprivation therapy on prostate metabolism as detected by combined magnetic
resonance imaging and 3D magnetic resonance spectroscopic imaging. Magn Reson Med. 46: 49--57
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J (2001b) Localized prostate cancer: effect of hormone deprivation therapy measured by using combined three-dimensional 1H MR
spectroscopy and MR imaging: clinicopathologic case-controlled study. Radiology 221: 380--390
Müller-Lisse UG, Scherr M (2003) 1H-MR-Spektroskopie der Prostata: Ein Überblick. Radiologe 43: 481-488
Müller-Lisse UL, Hofstetter A (2003) Urologische Diagnostik des Prostatakarzinoms. Radiologe 43: 432—440
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Cancer: localization with three-dimensional proton MR spectroscopic imaging – clinicopathologic study. Radiology 213: 473--480
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prostate cancer: comparison of sextant biopsy, magnetic resonance imaging and magnetic resonance spectroscopy with step section
histology. J Urol 164: 400--404
TECHNICAL PROTOCOLS FOR FEMALE MRI OF THE PELVIS
PD, Dr. med, Karen Kinkel
Clinique des Grangettes, Chêne-Bougeries, Geneva, Switzerland
This workshop gives technical information to perform magnetic resonance (MR) imaging in the female pelvis.
Imaging protocols are adapted to the clinical question and the pelvic organ. General technical consideration
cover patient and coil positioning, pre-medication, sequences and contrast media. Case presentations helps
understanding why performance of a female pelvis MR needs MD supervision due to different slice
orientation and sequence adjustment according to findings during image acquisition.
General technical recommendation include prior fasting, supine position, long IV line to allow performance of
dynamic sequences, IM injection of peristaltic inhibitors, coil centering just below the umbilicus to cover mid
symphysis pubis up to L5, anterior saturation bands placed on subcutaneous fat of abdominal wall. Slice
orientation starts generally with sagittal T2-weighted images to allow subsequent parallel and perpendicular
positioning of slices according to the axis of the endometrial stripe within the uterus corpus. The sequence
protocol include at least two different orientations of T2-weighted Fast spin echo sequences with a minimum
TR of 4000 msec, TE of 90 msec, FOV of 30cm, matrix 256x512, 2-4 nex, 4-5mm slices. One native T1-
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weighted Fast Spin Echo sequences with a TR of 600 msec is mandatory for assessing hemorrhage, an
important diagnostic finding in patients with pelvic pain or large fibroids. Fat suppression is used
subsequently whenever T1-hyperintense abnormalities are identified (call for MD to check after native T1
(!!)). Main purpose of this sequence is the differentiation of blood (persistent white signal intensity in
endometriomas or hemorrhagic cysts) from fat (decreased signal intensity in ovarian teratoma) [1]. Postcontrast
enhanced T1-weighted sequences profit from fat suppression when questions concerning adnexal
mass origin, bladder or rectal wall abnormalities are raised [2].
IV Contrast injection is mandatory for uterine and ovarian cancer staging and characterization of adnexal
masses [3-5]. Contrast media is helpful in patients with severe endometriosis to diagnose bladder or rectal
endometriosis [6]. In patients with large pelvic masses of unknown origin, contrast injection helps to visualize
the strongly enhanced normal myometrium. Enhancement degree of myometrial abnormalities helps to
confirm necrotic leiomyomas (no enhancement), adenomyosis (little enhancement) and eventually sarcoma
(hypervascular compared to myometrium). A dynamic mode of image acquisition every 1-2 minutes
increases diagnostic confidence to diagnose myometrial invasion of endometrial cancer due to strong early
enhancement of the normal myometrium at about 90 seconds and decreased enhancement within the
invaded portion of the myometrium [7].
Intra-rectal contrast medium is not necessary except in patients with anal insufficiency. Diagnosis of rectal
endometriosis may require water enema in specific cases [6].
Additional useful sequences include MR-urography (ureteral involvement or compression) [8], MRangiography
(dilated ovarian veins), and dynamic pelvic floor MRI with or without proctography (to diagnose
clinically questionable pelvic organ displacement, prolapse or enteroceles) performed during straining.
References
1. Yamashita Y, Torashima M, Hatanaka Y, Harada M, Sakamoto Y, Takahashi M, Miyazaki K, Okamura H. Value of phase-shift
gradient-echo MR imaging in the differentiation of pelvic lesions with high signal intensity at T1-weighted imaging. Radiology 1994,
191: 759-764.
2. Bipat S, Glas AS, van der Velden J, Zwinderman AH, Bossuyt PM, Stoker J. Computed tomography and magnetic resonance imaging
in staging of uterine cervical carcinoma: a systematic review. Gynecol Oncol 2003, 91: 59-66.
3. Kinkel K, Kaji Y, Yu KK, Segal MR, Lu Y, Powell CB, Hricak H. Radiologic staging in patients with endometrial cancer: a metaanalysis.
Radiology 1999, 212: 711-718.
4. Forstner R, Hricak H, Occhipinti KA, Powell CB, Frankel SD, Stern JL. Ovarian cancer: staging with CT and MR imaging. Radiology
1995, 197: 619-626.
5. Kinkel K, Lu Y, Mehdizade A, Pelte M, Hricak H. Incremental value of a second imaging test to characterize a sonographically
indeterminate ovarian mass: a meta-analysis and a Bayesian analysis. Radiology 2005, in press.
6. Bazot M, Darai E, Hourani R, Thomassin I, Cortez A, Uzan S, Buy JN. Deep Pelvic Endometriosis: MR Imaging for Diagnosis and
Prediction of Extension of Disease. Radiology 2004, 232: 379-389 Epub 2004 Jun 2017.
7. Yamashita Y, Harada M, Sawada T, Takahashi M, Miyazaki K, Okamura H. Normal uterus and FIGO stage I endometrial carcinoma:
dynamic gadolinium-enhanced MR imaging. Radiology 1993, 186: 495-501.
8. Balleyguier C, Roupret M, NGuyen T, Kinkel K, Helenon O, Chapron C. Ureteral endometriosis: The role of Magnetic Resonance
Imaging. J Am Assoc Gynecol Laparosc 2004, 4: 530-536.
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CONTRAST MEDIA GUIDELINES
EFFECTS OF IODINATED CONTRAST MEDIA ON BLOOD AND
ENDOTHELIUM
P. Aspelin, MD, F. Stacul, MD, A.J. van der Molen, MD, T. Almén, MD, M.F. Bellini, MD, J.Å. Jakobsen,
MD, R. Oyen, MD, J.A.W. Webb, MD, H.S. Thomsen, MD, S.K. Morcos, MD, and the members of contrast
media safety committee of European Society of Urogenital Radiology (ESUR)
ESUR statement on effects of iodinated contrast media on blood and endothelium
The clinically important adverse effect of iodinated contrast media on blood and endothelium is thrombosis. It
is recognized that:
• All contrast media have anticoagulant properties, especially ionic agents.
• High osmolar ionic contrast media may induce thrombosis due to endothelial damage, particularly in
phlebographic procedures.
• Drugs and interventional devices that decrease the risk of thromboembolic complications during
interventional procedures minimize the importance of the effects of contrast media.
Guidelines
• Meticulous angiographic technique is mandatory and is the most important factor in reducing
thromboembolic complications.
• Low- or iso-osmolar contrast media should be used for diagnostic and interventional angiographic
procedures including phlebography.
ABSTRACT
Purpose
To assess the effects of iodinated contrast media on blood components and endothelium based on
experimental and clinical studies and to produce clinical relevance guidelines for reducing thrombotic and
hematologic complications following the intravascular use of contrast media.
Material and Methods
A report has been drafted after review of the literature and discussions among the members of the Contrast
Media Safety Committee of the European Society of Urogenital Radiology. The final report was produced
following discussion at the 12 th European Symposium on Urogenital Radiology in Ljubljana, Slovenia (2005).
Results and Conclusion
Experimental data indicate that all iodinated contrast media possess an anticoagulant effect and that this
effect is greater with ionic contrast media. Several of the in-vitro and experimental in-vivo studies on
hematologic effects of contrast media have not been confirmed by clinical studies. Low- or iso-osmolar
contrast media should be used for diagnostic and interventional angiographic procedures including
phlebography. Meticulous angiographic technique is the most important factor for reducing the thrombotic
complications associated with angiographic procedures. Drugs and interventional devices that decrease the
risk of thromboembolic complications during interventional procedures minimize the importance of the effects
of contrast media.
Key-Words: Iodinated contrast media, coagulation, endothelium, blood cells, thrombosis.
Introduction
Iodinated contrast media are widely used either to visualize blood vessels (angiography) or to enhance the
density of the parenchyma of different organs. In both instances they are administered intravascularly and
ideally their effects on blood and endothelium should be minimal. However, all contrast media have some
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effects on the endothelium, blood and its constituents. There is a vast literature on these effects both in vitro
and in vivo. The Contrast Media Safety Committee of the European Society of Urogenital Radiology (ESUR)
decided to review the literature and based on this review to draw up guidelines.
Iodinated contrast media may be either ionic or nonionic and they all produce various effects on blood
components. These effects are thought to be caused by the chemical nature of contrast media, their
electrical charge, and by the viscosity and the osmolality of the solution in which they are given although
contribution by pharmaceutical excipients and Ph of the contrast agent solution cannot be ruled out. Different
contrast media have varying effects on the many components of the blood. The present paper is not intended
to be a complete review of all the available data, but to summarize the effects from a clinical point of view in
order to decide whether there are important differences between the types of iodinated contrast media
currently available for clinical use.
The hematologic effects of iodinated contrast media have been divided into the following categories: red
blood cells, white blood cells, endothelium, platelets, coagulation and fibrinolysis.
Red Blood Cells
The effect of contrast media on red blood cells can be divided into the effects on morphology, aggregation
and rheology (flow properties of the blood). When iodinated contrast media come into contact with red blood
cells while they are only minimally diluted, the normal discoid shape of the red blood cells changes [1, 2].
Two changes caused by extraction of water may occur: either shrinkage of the red blood cells producing a
dessicocyte or changes in shape called echinocyte or stomatocyte deformation.
Red blood cell morphology
Dessicocyte formation is an in vitro effect of dehydration of the red blood cell in a fraction of RBC and has
been observed when exposed to high concentrated contrast media and is proportional to the osmolality of
the contrast media to which it is exposed [1].
Echinocyte formation in vitro is dependent on the chemotoxicity (including electrical charge, pH or salt
concentration) [3] and not the osmolality of the contrast agent. All contrast media including the iso-osmolar
dimers may induce some degree of echinocyte formation and stomatocyte deformation is seen more
common with dimers [4, 5].
Red blood cell aggregation
Contrast media in vitro cause disaggregation of red blood cell rouleaux formation and not aggregation as
sometimes is believed [5]. The reason for the misunderstanding could be that contrast media make red cells
more rigid causing precapillary stasis which can be mistaken for increased red blood cell aggregation [6, 7].
Blood rheology
The combined effect of the dessicocytes and echinocytes is reduced plasticity of the red blood cells [6, 7, 8].
Plasticity is essential for the smooth flow of red blood cells through small capillaries and when it is lost there
is a decrease in blood flow especially after intraarterial injections [9-12]. Pure echinocyte and stomatocyte
formation without any dehydration of red blood cells produces only minor rheological change [1, 2]. However,
the overall in vivo effect is a mixture of the effect of contrast media on red blood cell morphology, rigidity,
viscosity and vascular tone and is also dependent on external parameters, e.g. shear stress. Contrast media
can induce both vasoconstriction and vasodilatation in different organs [13-16]. In the pulmonary circulation
contrast media can induce red cell rigidity and pulmonary arterial vasoconstriction leading to an increase in
pulmonary vascular resistance [12-15]. In the kidney contrast media can reduce the blood flow in the vasa
recta in the medulla [16]. It is not clear whether this effect is mainly caused by stasis due to vasoconstriction
or by increased red blood cell aggregation in vivo. The morphological red cell changes may also affect the
capacity for oxygen delivery and pH-buffering [17]. However these effects have not been proven to be of
importance in clinical studies [18].
The overall effect of contrast media on red blood cells has not been shown to be of clinical importance.
White Blood Cells
The function of the white blood cells is mainly host defense, but their interactions with the endothelial cells
and platelets are also important. White blood cells must be able to adhere to the endothelium and migrate
through the vessel wall in order to phagocytize and inactivate toxic products. This involves adherence,
chemotaxis, degranulation and phagocytosis. In vitro studies have shown that all these processes are
affected by contrast media.
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Phagocytosis
Contrast media reduce the ability of white blood cells to exhibit phagocytosis [19-21]. This effect is studied
and observed only with ionic high osmolar contrast media. The clinical importance of these in-vitro
observations is not known.
Chemotaxis, Granulocyte adherence and Inflammation
Contrast media have been shown in vitro to inhibit the chemotoxic response of white blood cells. In vivo
studies have not shown this finding to be significant [22]. All contrast media decrease the adherence property
of white blood cells [23-26]. Contrast media may interfere with the inflammatory response of white blood cells
in the body [27-29].
There are no clinical data to suggest that any of these interactions of contrast media and white blood cells
are of clinical importance.
Endothelium
Endothelial cells contribute to the regulation of many aspects of vascular homeostasis, including coagulation,
fibrinolysis and platelet function. In addition they are important modulators of vascular tone, primarily by the
regulated secretion and rapid clearance of powerful vasoactive mediators such as prostacyclin, nitric oxide,
endothelin and adenosine. The endothelium also controls solute permeability and leukocyte movement
during the generation of inflammatory and immune responses [, 30].
Endothelial cells are exposed transiently to high concentrations of contrast media following intravascular
administration. The endothelial effects of contrast media may contribute to the hemodynamic disturbances,
thrombosis and pulmonary edema associated with the intravascular use of these agents.
Modulation of the production of endothelial vasoactive substances plays an important role in mediating the
hemodynamic effects of contrast media particularly in the kidney [31]. Contrast media can increase the
release and expression of the potent vasoconstrictor peptide endothelin by the endothelial cells [32]. In
addition, contrast media may decrease the endothelial production of nitric oxide by reducing the activity of
the enzyme nitric oxide synthase which is responsible for the endogenous synthesis of this vasodilator [33,
34]. How contrast media increase the release of endothelin or reduce the production of nitric oxide is not
fully understood.
Contrast media, particularly high osmolality ionic agents, have cytostatic and cytotoxic effects on endothelial
cells which may precipitate thrombosis [35-41]. In addition, contrast media can induce apoptosis
(programmed cell death) of endothelial cells [42]. An increase in the frequency of apoptosis in the
endothelium may alter vascular homeostasis including coagulant and thrombotic properties, permeability and
tone of the blood vessel wall as well as vessel growth and angiogenesis [42].
The biocompatibility of contrast media is influenced both by osmolality and chemical structure, particularly
the presence of carboxyl groups in the molecules of the ionic agents. In the nonionic media the absence of
carboxyl groups and the presence of many hydroxyl groups which increase hydrophilicity markedly improve
biocompatibility and significantly reduce cytotoxicity [60-63]. Ionic contrast media, in particular high osmolar
agents, have greater effects on enzymes, higher affinity to proteins and lipids in comparison to nonionic
media and can induce injury to cell membranes and interfere with cell metabolism [43-44]. In addition,
contrast media can penetrate endothelial cells forming dense granules on the luminal surface and pinocytotic
vesicles [45].
Ionic contrast media may increase vascular endothelial permeability leading to pulmonary edema [46-51].
Subclinical pulmonary edema without obvious signs or symptoms of respiratory distress is thought to be
common after intravascular use of contrast media but its true incidence is difficult to establish [46].
Pulmonary edema produced by contrast media could also be responsible for the increase in the pulmonary
vascular resistance (PVR) caused by these agents [46]. Experimental studies have shown that ioxaglate
induced the largest increase in PVR of the isolated rat lung preparation and more marked pulmonary edema
compared to other classes of contrast media [47-51]. However, these experimental observations have not
been confirmed in larger clinical studies [52].
The endothelial effect of high osmolar ionic contrast media is of clinical importance in phlebography because
of the increased frequency of thrombosis after the procedure.
Platelets
Briefly, platelets adhere to exposed collagen, von Willebrand factor and fibrinogen at the site of arterial injury
(adhesion step). Adherent platelets are then activated by mediators such as thrombin, collagen, ADP,
serotonin, etc. (activation step). Activated platelets degranulate and secrete chemotaxins, clotting factors and
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vasoconstrictors, thereby promoting thrombin generation, vasospasm and additional platelet accumulation
(aggregation step) (53) (54). Therefore, the interaction of contrast media with platelets I assessed, each step
of platelet physiology should be evaluated separately.
Experimental effects
Platelet adhesion: Grabowski et al. (55) showed that in vitro platelet adhesion/aggregation was inhibited in
the order diatrizoate > ioxaglate > iohexol > saline. However, these effects rapidly diminished because of
hemodilution. In a baboon study (56), contrast media were found to inhibit platelet deposition on stents in the
order ioxaglate > iohexol = iodixanol > saline.Thus, all contrast media inhibit platelet adhesion, with ionic
agents being more potent than nonionics.
Platelet activation by thrombin: In vitro platelet activation by thrombin was inhibited by low osmolar ionic
contrast media whereas nonionic monomeric and dimeric contrast media did not affect it (57).
Direct platelet activation: Direct activation of platelets (i.e. degranulation and release of the procoagulant
content of dense bodies and α-granules) was induced in vitro by nonionic monomeric contrast media. Lesser
activation was caused by high-osmolar ionic contrast media and there was no activation by low-osmolar ionic
and nonionic dimeric contrast media [3-58]. Chronos et al [3] showed that blood from patients anticoagulated
with heparin and pretreated with aspirin in preparation for percutaneous coronary angioplasty (PTCA)
showed the same pattern of nonionic monomeric contrast medium-induced platelet activation as normal
subjects.
Platelet aggregation: An inhibitory effect of contrast media on platelet aggregation was first described by Zir
et al. in 1974 [59] and has been widely investigated since. Ionic contrast media, both high- or low-osmolar,
inhibit in vitro platelet aggregation (induced by mediators such as thrombin, ADP or collagen) more than
nonionic agents (monomeric or dimeric) [60-61]. Potentiation of the anti-thrombotic effects of clopidogrel, an
anti-aggregant drug, has been found in rats with an ionic low osmolar contrast medium but not with a
nonionic monomer [62].
Clinical pharmacology studies
Clinical pharmacology studies comparing the different categories of contrast media, however, led to more
equivocal conclusions than in vitro or animal studies.
In patients, no significant platelet activation (P-selectin expression) was found following left ventriculography
or coronary angiography with iohexol [63]. Similarly, Arora et al. [64] and Brzosko et al [65] did not find a
significant difference between ionic and nonionic contrast media when platelet degranulation markers were
measured in peripheral venous samples. Polanowska et al. [66] reported an increase in the venous level of
β-thromboglobulin following arteriography with a high osmolar contrast agent. Conversely, in another study
[67], following cardiac catheterization, no platelet activation was found with ioxaglate whereas serotonin
release was detected following injection of a nonionic monomer. It is worth noting that most of these studies
(except Albanese et al.) evaluated peripheral venous and not local blood samples and that arterial
catherization itself may activate platelets.
With respect to platelet aggregation, most clinical pharmacology studies have shown a higher antiaggregatory
effect for ionic agents than nonionic monomers, as recently confirmed by Dalby et al.[68, 61].
However, one study did not reveal difference between these categories of contrast media [69].
The clinical impact of these in vitro and experimental in vivo changes is debatable and is discussed in the
section on coagulation.
In summary, there are no clinical data to suggest that the effect of nonionic contrast media on platelets
induces increased coagulation. The mechanisms responsible for the effects of contrast media on platelets
are still unclear and clinically significant effects have not been shown.
Coagulation
In vitro effects of contrast media
All contrast media inhibit blood coagulation but to different extents. Prothrombin time, reptilase time,
activated partial thromboplastin time and recalcification clotting time are significantly increased in proportion
to the dose of the contrast media [61]. Comparison of assays of fibropeptide A and thrombin-antithrombin
complex between ionic agents (both monomeric and dimeric) and nonionic monomers showed that
coagulation times were shorter for nonionic monomers, but were always longer than in the controls [52, 70-
75].
107

The ionic dimer ioxaglate shows similar anticoagulant activity to the ionic monomers [61]. In one study the
nonionic dimer iodixanol was significantly less anticoagulant than the nonionic monomer iohexol [58] while in
another study it was reported that iodixanol affects the bleeding time similarly to nonionic monomers [76].
However, the precise mechanisms responsible for this inhibition are still unclear. It has been suggested that
the main factors are inhibition of activation of factor X, which leads to the formation of thrombin from
prothrombin [61, 77, 78] and inhibition of fibrin polymerization [69, 77, 79, 80]. Al Dieri et al [81, 82] showed
that ioxaglate blocks feedback activation of factors V and VIII, significantly inhibits platelet dependent
thrombin generation and boosts the effect of abciximab, whereas iodixanol does not. Interference with the
assembly of fibrin monomers by contrast media results in poor fibrin stabilization of clots [3, 71].
Therefore, ionic monomers and dimer have similar anticoagulant activity in vitro which is more pronounced
than that of nonionic monomers and dimers. Nonionic monomers probably have more anticoagulant effect
than nonionic dimers.
Clinical trials
Clinical data are less easy to evaluate because of patient related and procedure related variability (state of
the haemostatic system, condition of the vessel wall, use of guidewires, catheters, balloons, stents). Because
of the rapid clearance of contrast media, their anticoagulant effect is local rather than systemic and their
effect may be not significant if measured in distant peripheral blood vessels.
Following the in vitro observation by Robertson [83] of more frequent clot formation in blood contaminated
syringes with nonionic monomers than with ionic agents, a few case reports of thrombotic complications in
diagnostic angiography with nonionic monomers were published [84-86]. However, trials have shown no
clinical evidence of significant differences in thrombotic complications when ionic agents are compared to
nonionic monomers for coronary angiography [87, 88].
Randomized trials comparing ioxaglate to nonionic monomers during PTCA have produced conflicting results
[89-95]. In the two studies with the largest number of patients, one showed no significant difference between
ioxaglate and iomeprol in the incidence of sudden vessel occlusion [93] while the other showed a trend
toward less thromboembolic complications with ioxaglate compared to ioversol [94]. Scheller et al [96]
reported that patients undergoing stent placement had fewer acute and subacute stent occlusions when
imaged using ioxaglate (versus multiple nonionic agents). However, Danzi et al [95] recently reported that
nonionic monomers (iopamidol and iopromide) did not adversely affect stent patency when compared to
ioxaglate. The considerable periprocedural use of antiplatelet agents may explain their results. A metaanalysis
comparing nonionic monomers to ioxaglate showed a significant reduction of coronary vessel abrupt
occlusions with ioxaglate [97]. Iodixanol was compared to ioxaglate in three trials. In one, no significant
differences with regard to Major Adverse Cardiac Events (MACE) were detected [98]. In a second, I an a
high-risk patient group less abrupt vessel occlusions (p = 0.05) were found with iodixanol [99]. This
difference was more significant in patients that did not receive GpIIb/IIIa blockers. In the third, no significant
differences between the two media were found and there was no clear advantage with the use of an ionic
contrast agent in a large population of patients undergoing percutaneous coronary intervention for both
stable and unstable coronary artery disease [100].
Contrast media interactions with angiographic devices
Interactions of contrast media with angiographic devices have been investigated both in vitro and in vivo. The
syringe material greatly influenced the possibility of clot formation in syringes containing contrast media and
blood. Glass was a more powerful activator of coagulation than plastic and among the plastic syringes, those
made of styrene acrylonitrile activated coagulation more than those made of polypropylene. Furthermore
clots formed only in situations where there was very poor angiographic technique [79].
Teflon coated catheters and guidewires are more thrombogenic than polyurethane materials and much more
than polyethylene materials [80]. Idée and Corot [78] comprehensive reviewed the many factors influencing
clotting in catheters including the length of the procedure, blood/catheter contact time, volume of blood in the
catheter, size and type of the catheter, type of contrast material and degree of blood/contrast medium
mixture in the catheter. Some of these factors are difficult to control or standardize in clinical studies.
Therefore catheter and guidewire materials probably play a significant role in clinical studies of contrast
media and coagulation. The use of equipment with technically improved surfaces will probably largely
overcome this problem.
108

Fibrinolysis
Contrast media impede fibrinolysis and delay the onset of lysis by recombinant tissue-type plasminogen
activator (rt-PA), urokinase and streptokinase [101]. This effect is reduced by increasing the concentration of
the lysis agent. Contrast media cause fibrin to form in long/thin fibrils, which have a lower mass/length ratio
and are more resistant to fibrinolysis [102-103]. In vitro studies have shown that diatrizoate and iohexol delay
the onset of lysis induced by all lysis agents. However, ioxaglate delayed the onset of lysis by rt-PA and
urokinase but not by streptokinase [101]. Another in vitro study showed that thrombi formed with iodixanol
and iohexol are larger and more resistant to thrombolysis when compared to thrombi formed with ioxaglate
[104]. In vivo studies in dogs showed that alteplase-induced thrombolysis could be delayed by iohexol and
amidotrizoate whereas ioxaglate had no significant effects [105]. In a small group of patients undergoing
pulmonary angiography iohexol significantly increased plasma levels of PAI-1, an inhibitor of t-PA and
urokinase, while ioxaglate did not [106]. Other effects on fibrinolysis caused by interactions of contrast media
with concomitantly given drugs are described in more detail in another paper from the ESUR Contrast Media
Safety Committee [107].
Summary
All contrast agents may alter the morphology and function of red blood cells. However, the overall effect of
contrast media on red cells has not been shown to be of clinical importance. Similarly the effect on white
blood cells has not been shown to be clinically important.
In vitro studies have shown that nonionic monomers cause more activation of platelets than ionic contrast
media. Iso-osmolar dimeric contrast media have not been shown to activate platelet function. Clinical studies
have not confirmed these in-vitro observations.
Contrast media have cytostatic, cytotoxic and apoptotic effects on endothelial cells. These effects are more
evident with ionic contrast media, in particular high osmolar agents, than with nonionic media. Contrast
media induced endothelial injury may play a role in the pathophysiology of the effects of contrast media.
These include hemodynamic effects, thrombosis and contrast media-induced pulmonary edema.
The risk of thrombosis induced by contrast media relates to the combined effect on platelets, endothelial cells
and coagulation factors. In clinical practice, high osmolar contrast media can induce thrombosis after
intravenous injection mainly because of endothelial injury produced by the high osmolality. This effect is less
with nonionic low-osmolar and iso-osmolar contrast media.
All contrast media have anticoagulant properties, and ionic media are more anticoagulant than nonionic
compounds. Acute and subacute thrombus formation remains a topic of debate including the use of lowosmolar
ionic contrast media in preference to low-osmolar nonionic contrast media in coronary interventions.
However, the general consensus is that good angiographic technique is the most important factor in reducing
thrombotic complications. Drugs and interventional devices that decrease the risk of thromboembolic
complications during interventional procedures minimize the importance of the effects of contrast media
[108].
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USE OF CONTRAST MEDIA IN THE EMERGENCY DEPARTMENT
James H. Ellis, M.D.
University of Michigan, USA
Objectives
The intravascular administration of radiographic iodinated contrast media (RICM) provides great benefit to
patients in the performance of diagnostic and interventional procedures, and its use is generally
straightforward and without complication. Some situations, however, are more problematic: the patient at
higher risk for an acute reaction, the patient taking metformin, and the patient who is pregnant or breastfeeding.
In the Emergency Department, the press of time constraints adds an additional dimension to the
situation. Providing assistance in assessing and managing these patients is the objective.
Avoiding the Use of Intravascular Contrast Material
In many clinical situations, the use of intravascular RICM is not needed, or in some cases, may potentially
interfere with interpretation. Perhaps the best example is CT of the brain for intracerebral or subarachnoid
hemorrhage. Because intracranial hemorrhage almost always has higher attenuation than normal brain
tissue, the blood itself provides its own contrast with normal structures. RICM, by enhancing both normal and
abnormal tissues, could obscure acute or subacute hemorrhage. The detection by CT of a ruptured
abdominal aortic aneurysm is another test where intravascular RICM is not needed for the basic diagnosis.
Although many institutions use intravenous contrast enhancement for CT of the appendix in suspected
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appendicitis, CT maintains high accuracy for appendicitis even in the absence of IV contrast (and in some
studies, the additional absence of oral and rectal contrast) in both adults and children [1-3]. The use of
noncontrast helical CT for acute urinary tract colic has essentially replaced the excretory urogram wherever
CT is available for this indication [4] although outcomes studies are few [5].
In other situations, if there is any question about the patient’s ability to tolerate RICM, alternate tests may be
substituted for those that might ordinarily involve the use of RICM. Many causes of abdominal pain can be
detected on noncontrast CT even though contrast-enhanced CT may provide better images or additional
information. For example, noncontrast CT can usually detect any extrapancreatic spread or complications of
pancreatitis, though it may not be useful to detect pancreatic necrosis [6]. Ultrasound is widely used as a less
expensive alternative to CT, but is of particular value when the patient has contraindications to contrast
material. Magnetic resonance imaging is superior to CT for evaluation of most pathologic processes of the
central nervous system. MR of the abdomen can diagnose many acute conditions. In most patients with
contraindications to RICM, gadolinium contrast agents for MR have a tolerable safety profile.
However, noncontrast CT, ultrasound, and MR are limited in evaluation of the severe trauma patient,
particularly for traumatic injuries to the thoracic and abdominal internal organs. In these and other emergency
cases, it may be preferable to perform a study using RICM. In these circumstances, it is important to deal
expediently with conditions in which RICM poses a higher risk to the patient than to the normal population.
The Patient at Higher Risk for an Acute Allergic-Like Reaction
Adverse reactions to RICM are encountered in as many as 3.1% of patients receiving intravenous injections
of low osmolality nonionic contrast media (LOCM) and 12.7% of patients receiving intravenous injections of
high osmolality ionic contrast media (HOCM) [7]. Fortunately, the majority of these reactions are mild and
clinically insignificant. Severe and very severe reactions (the latter requiring hospitalization) have been noted
much less frequently, in only 0.04% and 0.004% of patients receiving intravenous injections of LOCM and
0.22% and 0.04% of patients receiving intravenous injections of HOCM, respectively [7]. The vast majority of
patients who have severe, even potentially life-threatening, reactions respond to rapid and aggressive
treatment [8]. Fatal reactions to both types of contrast media are exceedingly rare, having been encountered
in as few as 1:170,000 patients injected with either agent [7].
Adverse reactions can be broadly classified as idiosyncratic or nonidiosyncratic [8]. Idiosyncratic reactions
have manifestations identical to those seen with true allergic reactions. Nonidiosyncratic reactions have
manifestations that do not resemble allergic reactions, but instead are believed to reflect physiologic effects
of contrast media or direct toxicity of contrast media on a variety of organ systems.
Idiosyncratic reactions most often begin within 20 minutes of contrast media injection [8]. Their occurrence is
not related to the administered dose of contrast material. Although the manifestations of idiosyncratic
reactions are identical to those seen in patients having true anaphylactic reactions, reactions to contrast
material are not true allergic reactions in the vast majority of patients [9, 10]. Hence idiosyncratic reactions to
radiographic contrast material have been termed anaphylactoid or allergic-like rather than anaphylactic or
allergic reactions.
Certain groups of patients are more likely to have idiosyncratic reactions to RICM. Patients with a history of
prior contrast reaction have about four times the risk of an adverse reaction, and patients with a history of
allergies or asthma have about two to three times the risk of an adverse reaction, compared to patients who
do not have these histories [7]. Shellfish allergy is not a “special” allergy with respect to contrast media
injection, but should be managed in the same way as other non-contrast allergies (e.g., peanut, bee sting, or
penicillin allergies) [11].
To reduce the risk of a contrast reaction in these high-risk patients, premedication with steroids and H1
antihistamines is recommended, along with the use of LOCM. Other drugs such as H2 antihistamines and
ephedrine can be added to the regimen, but are not widely used [8, 12]. If the patient has had a prior severe
reaction to a specific contrast agent, switching to another brand of LOCM or iso-osmolality contrast agent
makes common sense but has not been scientifically tested.
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Various premedication protocols have been proposed for high-risk patients. Ours (with the drug schedule
adapted from [13, 14]) is:
Premedication: To reduce the risk of anaphylactoid reactions to radiographic contrast media.
Generally recommended for patients who have a history of:
Previous allergic-like reaction to contrast media
Other true allergies, particularly if multiple and/or severe
True asthma, particularly with frequent or severe attacks, or currently or recently symptomatic
Oral / Elective:
Prednisone 50 mg PO 13, 7, and 1 hour prior
and
Diphenhydramine (Benadryl) 50 mg PO (or IM) 1 hour prior to exam
(Patients should not drive after diphenhydramine.)
Intravenous / Urgent:
Hydrocortisone (Solu-Cortef) 200 mg IV stat and q 4 hour until exam complete
and
Diphenhydramine (Benadryl) 50 mg IV 1 hour before procedure if time permits
Thus one can shorten the preparation time to about 4 hours in the urgent Emergency Department situation. If
the patient has emergent need for RICM, the risk-benefit ratio must be considered. Intravenous
hydrocortisone and diphenhydramine can be (and in the emergent situation, frequently are) given
immediately before RICM in high-risk patients. This is a low-risk intervention but its effectiveness is unknown.
The Patient at Risk for Nephrotoxicity
Nephrotoxicity is covered in greater detail in another presentation. With respect to the Emergency
Department, however, it is worthwhile knowing if any of the typical actions taken to reduce the risk of
nephrotoxicity can be administered more speedily than usual. Although the usefulness of acetylcysteine in
the reduction of nephrotoxicity risk is debatable [15, 16], it can be given intravenously to reduce the time from
the start of premedication to the time the RICM can be administered. Studies using oral acetylcysteine
typically start premedication the day before the examination [15, 16]. In one study [17], oral administration
beginning one hour prior to RICM was not effective. However, in a study [18] using intravenous saline as the
control, contrast-induced nephrotoxicity was reduced by administering acetylcysteine intravenously beginning
30 minutes before the administration of RICM.
The choice of RICM may also affect the risk of nephrotoxicity, and presents no delay in obtaining a contrastenhanced
study. Low-osmolality contrast material has a lower incidence of contrast-induced nephrotoxicity
compared to high osmolality contrast material [19, 20]. Iso-osmolality contrast material may reduce the risk
even further, in high-risk patients [21, 22].
The Patient Taking Metformin
Metformin (generic, or alone or in combination in trade name drugs Glucophage, Glucovance, Avandamet,
Metaglip, and others), is an oral antihyperglycemic medication that is being prescribed with increased
frequency. Although metformin itself is not nephrotoxic, patients who are taking this drug and who happen to
develop renal failure (as a result of a contrast material injection or other renal insult) may rarely develop lactic
acidosis, which can be fatal [23-25]. The USA FDA drug package insert for metformin states that this agent
should be discontinued at the time that a contrast enhanced study is performed and should not be restarted
until the patient's renal function is documented to be normal a minimum of 48 hours after that study [26].
Some referring physicians may want their patients to have alternate glucose control over this time.
Some European authors [27, 28] have asserted that, if a patient undergoing a contrast examination has
normal renal function, metformin can be continued. This argument is based on literature reviews that show
that almost every case of metformin-related lactic acidosis occurred in patients with pre-existing renal
disease or other contraindication to metformin. However, the European Society of Urogenital Radiology
114

(ESUR) [29] recommends temporarily withholding metformin after RICM, in a manner similar to the FDA
directive.
The Pregnant Patient
Iodinated contrast media crosses the placenta. In general, intravenous contrast material should be avoided,
when possible, in pregnant women so as to eliminate any theoretical adverse effects on the fetus [30].
However, if contrast media administration is required, it can probably be safely injected (at least in the third
trimester) [31]. A guideline from the ESUR is available on the Society web site.
The Patient who is Breast Feeding
A number of studies have shown that the amount of contrast material excreted in breast milk is minimal. In
one study, it was determined that the amount of nonionic iohexol-350 ingested by a breast-fed baby within 24
hours of maternal contrast media injection (at a volume of 1 ml/kg) would equal only 0.2% of the allowed
pediatric dose for that infant [32]. Excretion of the MRI contrast agent gadopentetate dimeglumine is even
lower [33]. These studies indicate that there is no definite reason for a lactating mother to stop breast feeding
after a contrast media injection. Nonetheless, as an extra precaution, some researchers (and the USA FDA
package inserts) recommend that infants be fed formula and that the mother use a breast pump for 24 hours
following maternal contrast administration [33]. The American College of Radiology suggests that the mother
be informed about the safety of continuing to breast feed but be allowed to make her own choice [30]. A
guideline from the ESUR is available on the Society web site.
Conclusion
RICM is a valuable adjunct to diagnostic imaging. In most cases, it can be given in the emergent situation
without adverse events. Other situations present cautions or higher risks, but these can be managed
effectively with generally simple interventions.
References
1. Lane MJ, Liu DM, Huynh MD, Jeffrey RB Jr, Mindelzun RE, Katz DS. Suspected acute appendicitis: nonenhanced helical CT in 300
consecutive patients. Radiology 1999; 213:341-346
2. Mullins ME, Kircher MF, Ryan DP, Doody D, Mullins TC, Rhea JT, Novelline RA. Evaluation of suspected appendicitis in children
using limited helical CT and colonic contrast material. AJR 2001; 176:37-41
3. Hoecker CC, Billman GF. The utility of unenhanced computed tomography in appendicitis in children. J Emerg Med 2005; 28:415-421
4. Chen MYM, Zagoria RJ. Can noncontrast helical computed tomography replace intravenous urography for evaluation of patients with
acute urinary tract colic? J Emerg Med 1999; 17:299-303
5. Mendelson RM, Arnold-Reed DE, Kuan M, Wedderburn AW, Anderson JE, Sweetman G, Bulsara MK, Mander J. Renal colic: a
prospective evaluation of non-enhanced spiral CT versus intravenous pyelography. Australas Radiol 2003; 47:22-28
6. Paulson EK, Vitellas KM, Keogan MT, Low VH, Nelson RC. Acute pancreatitis complicated by gland necrosis: spectrum of findings on
contrast-enhanced CT. AJR 1999; 172:609-613
7. Katayama H, Yamaguchi K, Kozuka T, et al. Adverse reactions to ionic and nonionic contrast media. A report from the Japanese
Committee on the Safety of Contrast Media. Radiology 1990; 175:621-628
8. Cohan RH, Leder RA, Ellis JH. Treatment of adverse reactions to radiographic contrast media in adults. Radiol Clin NA 1996;
34:1055-1076
9. Carr DH, Walker AC. Contrast media reactions: experimental evidence against the allergy theory. Br J Radiol 1984; 57:469-473
10. Shehadi WH. Contrast media adverse reactions: occurrence, recurrence, and distribution patterns. Radiology 1982; 143:11-17
11. Coakley FV, Panicek DM. Iodine allergy: an oyster without a pearl? AJR 1997; 169:951-952
12. Marshall GD Jr., Lieberman PL. Comparison of three pretreatment protocols to prevent anaphylactoid reactions to radiocontrast
media. Ann Allergy 1991; 67:70-74
13. Greenberger PA, Halwig JM, Patterson R, Wallemark CB. Emergency administration of radiocontrast media in high-risk patients. J
Allergy Clin Immunol 1986; 77:630-634
14. Greenberger PA, Patterson R. The prevention of immediate generalized reactions to radiocontrast media in high-risk patients. J
Allergy Clin Immunol 1991; 87:867-872
15. Fishbane S, Durham JH, Marzo K, Rudnick M. N-Acetylcysteine in the prevention of radiocontrast-induced nephropathy. J Am Soc
Nephrol 2004; 15:251-260
16. Morcos SK. Prevention of contrast media nephrotoxicity – the story so far. Clin Radiol 2004; 59:381-389
17. Durham JD, Caputo C, Dokko J, Zaharakis T, Pahlavan M, Keltz J, Dutka P, Marzo K, Maesaka JK, Fishbane S. A randomized
controlled trial of N-acetylcysteine to prevent contrast nephropathy in cardiac angiography. Kidney Int 2002; 62:2202–2207
18. Baker CS, Wragg A, Kumar S, De Palma R, Baker LRI, Knight CJ. A rapid protocol for the prevention of contrast-induced renal
dysfunction: The RAPPID study. J Am Coll Cardiol 2003; 41:2114–2118
19. Rudnick MR, Goldfarb S, Wexler L, et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial.
Kidney Int 1995; 47:254-261
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20. Barrett BJ, Carlisle EJ. Metaanalysis of the relative nephrotoxicity of high- and low-osmolality iodinated contrast media. Radiology
1993; 188:171-178
21. Chalmers N, Jackson RW. Comparison of iodixanol and iohexol in renal impairment. Br J Radiol 1999; 72:701-703
22. Aspelin P, Aubry P, Fransson SG, Strasser R, Willenbrock R, Berg KJ. Nephrotoxic effects in high-risk patients undergoing
angiography. N Engl J Med 2003; 348:491-499
23. Assan R, Heuclin C, Ganeval D, George J, Girard JR. Metformin-induced lactic acidosis in the presence of acute renal failure.
Diabetologia 1977; 13:211
24. Bailey CJ, Turner RC. Metformin. N Engl J Med 1996; 334:574-579
25. Dachman AH . New contraindication to intravascular iodinated contrast material. Radiology 1995; 197:545
26. Rasuli P, French GJ, Hammond DI. Metformin hydrochloride all right before, but not after, contrast medium administration. Radiology
1998; 209:586-587
27. Nawaz S, Cleveland T, Gaines PA, Chan P. Clinical risk associated with contrast angiography in metformin treated patients: a clinical
review. Clin Radiol 1998; 53:342-344
28. McCartney MM, Gilbert FJ, Murchison LE, Pearson D, McHardy K, Murray AD. Metformin and contrast media – a dangerous
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28:523-526
33. Schmiedl U, Maravilla KR, Gerlach R, Dowling CA. Excretion of gadopentetate dimeglumine in human breast milk. AJR 1990;
154:1305-1306
ESUR GUIDELINES ON CONTRAST MEDIUM INDUCED NEPHROPATHY
Henrik S. Thomsen
Copenhagen University Hospital, DK
The term contrast medium induced nephropathy is widely used to refer to the reduction in renal function
induced by contrast media. It implies impairment in renal function (an increase in serum creatinine by more
than 25% or 44µmol/L (0.5 mg/dL)) occurred within 3 days following the intravascular administration of
contrast media and the absence of alternative etiology. Most authors use that definition which was endorsed
by ESUR in 1999 [1].
Contrast medium induced nephropathy is considered an important cause of hospital acquired renal failure [2,
3]. This is not surprising, since diagnostic and interventional procedures requiring the use of contrast media
are performed with increasing frequency. In addition, the patient population subjected to these procedures is
progressively older with more co-morbid conditions [4]. Prevention of this condition is important to avoid the
substantial morbidity and even mortality that can be sometime associated with contrast medium induced
nephrotoxicity. Even a small decrease in renal function may greatly exacerbate morbidity that is caused by
coexisting conditions [5, 6]. Sepsis, bleeding, coma, and respiratory failure are frequently observed in
patients with acute renal failure.
The patients at highest risk for developing contrast induced acute renal failure are those with pre-existing
renal impairment (> 132 µmol/L (1.5 mg/dL)) particularly when the reduction in renal function is secondary to
diabetic nephropathy [1, 7]. Diabetes mellitus per se without renal impairment is not a risk factor [7]. The
degree of renal insufficiency present before the administration of contrast media determines to a great extent
the severity of contrast media nephrotoxicity. Large doses of contrast media and multiple injections within 72
hours increase the risk of developing contrast medium induced nephropathy. The route of administration is
also important and contrast media are less nephrotoxic when administered intravenously than when given
intra arterially in the renal arteries or in the aorta proximal to the origin of the renal blood vessels [1].
Determination of serum creatinine
Serum creatinine is often used to determine the renal function and to identify high risk patients in spite of the
limitations of this measurement. However, serum creatinine is not an ideal marker of renal function. The
serum creatinine level depends on muscle mass and is not usually raised until the glomerular filtration rate
has fallen by at least 50%. Endogenous serum creatinine clearance as a measure of glomerular filtration rate
is also inaccurate especially when renal function is low because of a compensatory increase in tubular
116

secretion which limits its validity as a glomerular filtration marker. Radionuclide techniques are preferable [8]
but each of these tests is labor-intensive and impossible to perform in all patients undergoing contrast
enhanced imaging. Alternatively, renal function can be estimated by using specially derived predictive
equations. The most accurate results are obtained with the Cockroft-Gault equation whereas the most
precise formula is the Modification of Diet in Renal Disease (MDRD) study equation [9]. Unfortunately, the
predictive capabilities of these formulae are suboptimal for ideal patient care [9]. However, these methods
are far superior for assessing renal function compared to a simple serum creatinine measurement. Another
alternative is to use cut-off values for serum creatinine as an indicator of several levels of renal impairment.
However, the use of cut-off levels (especially the low levels) will include several patients with normal renal
function and use of the cut-off high levels will exclude patients with renal impairment [10]. Despite the
inaccuracies of serum creatinine measurements it is an adequate measure for identifying those patients at
risk for contrast medium nephropathy as patients with normal serum creatinine (< 132 µmol/L (1.5 mg/dL))
has almost no risk [7].
A questionnaire designed to elicit a history of renal disorders as well as additional risk factors for contrast
media induced nephropathy may identify patients with normal serum creatinine in whom blood testing would
be unnecessary [11]. However, a questionnaire does not completely exclude the presence of renal
insufficiency, but it is practical and cost-efficient. As a matter of fact several patients referred from hospital
departments have had their serum creatinine determined for other reasons within the last year and one can
glance at these figures.
To avoid contrast medium induced nephrotoxicity
Several measures have been recommended to reduce the incidence of contrast medium induced
nephropathy [12,13]. They include volume expansion, hydration with intravenous administration of normal
saline solution (NaCl 0.9%) or half strength saline solution (NaCl 0.45%), infusion of sodium bicarbonate in
stead of normal saline, infusion of mannitol, pharmacological manipulation (administration of atrial natriuretic
peptide, loop diuretics, calcium antagonists, theophylline, dopamine, dopamine-1 receptor antagonist
fenoldopam, acetylcysteine), use of low-osmolar non-ionic contrast media instead of high-osmolar ionic
contrast media, use of isoosmolar contrast media instead of low-osmolar contrast media, gadolinium based
contrast media instead of iodine based contrast media for radiography and CT, hemodialysis rapidly after
contrast administration, hemofiltration during and after contrast administration, an injection of small volume of
contrast medium, and avoiding short intervals (less than 48 hours) between procedures requiring
intravascular administration of contrast media.
Of all the above mentioned measures, extracellular volume expansion and use of low osmolar contrast
media have been found systematically to be consistently effective [1, 14-17]. Volume expansion can be
achieved with the intravenous injection of at least 100 ml/hr of 0.9% saline solution starting 4 hours before
contrast administration and continuing for 24 hours afterwards [1]. In areas with hot climate more fluid should
be given. This regime is suitable for patients who are not in congestive heart failure and are not allowed to
drink or eat before undergoing an interventional or surgical procedure. If there is no contraindication to oral
administration, free fluid intake should be encouraged. At least 500 ml of water or soft drinks before and
2500 ml for 24 hours after the procedure is recommended by ESUR. Recently, it has been suggested that
sodium bicarbonate offers a better protection than normal saline [18], but the experience is still limited.
Concurrent administration of nephrotoxic drugs such as gentamicin and non-steroid anti-inflammatory drugs
should also be avoided. Mannitol and furosemide enhances the risk if nephrotoxicity [14].
Over the years various regimes of pharmacologic manipulation have been suggested in order to reduce the
frequency of contrast medium induced nephropathy. The regimes have included 1) calcium channel blockers,
which prevent the influx of calcium ions through voltage-operated channels and hereby cause a vasorelaxant
effect in all vascular beds including the kidney, 2) selective dopamine-1 receptor agonist (fenoldopam) which,
in contrast to dopamine, increases both cortical and medullary blood flow, 3) endothelin antagonists, which
play an important role in renal vasculature, 4) non-selective adenosine receptor antagonist theophylline,
which also cause vascular dilatation and 5) acetylcysteine, which is an antioxidant and scavenger of oxygen
free radicals. Administration of these drugs has been shown both to be effective in preventing contrast
medium induced nephropathy in some studies and to be without any effect in others. Even the result of
several metaanalyses has been conflicting. Therefore, the ESUR does not for the time being recommend any
pharmacological manipulation for routine use in prevention of contrast medium induced nephropathy.
The ESUR recommends that non ionic media are used in patients at risk of developing contrast medium
induced nephropathy. At this moment it is unclear whether there is a different in nephrotoxic potential
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etween low osmolar non ionic monomeric and iso-osmolar non ionic dimeric contrast media. Various
studies have reported conflicting results. However, it is clear that all contrast media can cause nephropathy
in patients with risk factors.
Dialysis and contrast media administration
Dialysis has been used in the prevention of contrast medium induced nephropathy. Hemodialysis and
peritoneal dialysis safely remove both iodinated and gadolinium based contrast media from the body [19].
The effectiveness of hemodialysis depends on many factors including blood and dialysate flow rate,
permeability of dialysis membrane, duration of hemodialysis and molecular size, protein binding,
hydrophilicity and electrical charge of the contrast medium. Generally several hemodialysis sessions are
needed to removal all contrast medium, whereas it takes 3 weeks for continuous ambulatory dialysis to
remove the agent completely. The ESUR concluded that there is no need to schedule the dialysis in relation
to the time of the injection of a contrast medium or the injection of the contrast agent is scheduled in relation
to the dialysis program.
Hemodialysis does not protect poorly functioning kidneys against contrast medium induced nephropathy [20-
23]. In addition, hemodialysis may cause deterioration of renal function through activation of inflammatory
reactions with the release of vasoactive substances that may induce acute hypotension.
Hemofiltration which is a continuous form of renal replacement therapy requires the intravenous infusion of
large volume of isotonic replacement fluid (1000 ml/h). This is exactly matched with rate of ultrafiltrate
production, so that no net fluid loss or overload occurs. A single study has shown that in patients with chronic
renal failure who are undergoing coronary interventions, hemofiltration given in intensive care unit (ICU)
setting appears to be effective in reducing the incidence of contrast medium induced nephropathy as well as
reduces the rate of in-hospital mobidity and mortality [24]. However, the procedure is very costly and requires
intensive treatment setting. Further studies are strongly warranted before this costly method can be
recommended for routine use.
Use of gadolinium–based contrast media for radiographic examinations
Gadolinium based contrast agents are believed to be safe and not nephrotoxic in the standard MRI doses up
to 0.3 mmol/kg body weight. Therefore it has been suggested that gadolinium-based contrast media could be
used in place of iodinated agents for radiological examinations in patients with significant renal impairment
[25]. However, the dose requirement for a satisfactory diagnostic study differs between MRI and radiography
because different properties of the gadolinium are being used in the two techniques. The commonly used
dose for body CT is 150 ml of a 300 mg I/ml (2.38 mmol I/ml) solution. The standard dose for contrastenhanced
MRI is 0.2 ml/kg body weight of a 0.5 mmol/ml gadolinium-based contrast agent. For body CT, a
patient weighing 70 kg would receive 120 mmol of the iodinated agent molecule and 360 mmol of iodine. For
MRI, this same 70 kg patient would receive 7 mmol of the gadolinium based agent molecule and 7 mmol of
gadolinium [25]. Thus, the number of iodinated contrast agent molecules administered would be almost 17
times that of gadolinium containing molecules, and the number of iodine atoms administered is 51 times that
of gadolinium.
In 3.5% of 195 patients with abnormal pre-examination creatinine clearance levels, acute renal failure
(anuria) developed after gadolinium-based contrast medium administration; for MR-angiography the
incidence was 1.9% and for digital subtraction angiography it was 9.5% [26]. Dialysis was required in 3 of the
7 patients who developed acute renal failure. The doses of gadolinium-DTPA ranged from 0.31 to 0.41
mmol/kg for MR angiography and 0.27 to 0.42 mmol/kg for digital subtraction angiography. Several other
reports have shown the nephrotoxic potential of gadolinium based contrast media [27-31]. An experimental
study in pigs has indicated the gadolinium based contrast media are more nephrotoxic than iodinated
contrast media [31]. Thus, the use of gadolinium based contrast media for radiographic examinations cannot
be recommended to avoid nephrotoxicity in patients with renal impairment [25].
Administration of contrast media to diabetics taking metformin
The use of contrast media in patients receiving metformin should be done with care. Contrast media can
induce a reduction in renal function leading to retention of metformin that may induce lactic acidosis, since
there is a very rapid onset of renal injury after administration of contrast medium [32]. However, there is no
conclusive evidence indicating that the intravascular use of contrast media precipitates the development of
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
within normal range before administration of metformin is resumed.
Conclusion
Measurement of S-creatinine must always be measured no longer 7 days before administration of iodinated
contrast in patients with 1) renal disease, 2) renal surgery, 3) proteinuria, 4) diabetes mellitus, 5)
hypertension, 6) gout and 7) recent intake of nephrotoxic drugs. The answers should be provided to the
department of radiology with the imaging request. In emergency situation serum-creatinine should always be
measured if the delay of the examination does not do any harm to the patient.
In case of increased serum-creatinine levels one should not 1) give high osmolar contrast media, 2)
administer large doses of contrast media, 3) administer mannitol and diuretics, particularly loop-diuretics and
4) perform multiple studies with contrast media within a short period of time and 5) continue metformin
administration 48 hours prior to contrast administration. It is of importance that one 1) makes sure that the
patient is well hydrated [give at least 100 ml (oral (e.g. soft drinks) or intravenous (normal saline) depending
on the clinical situation) per hour starting at least 4 hours before to 24 hours after contrast administration – in
warm areas increase the fluid volume], 2) uses low- or iso-osmolar contrast media, 3) stops administration of
nephrotoxic drugs for at least 24 hours, and 4) considers alternative imaging techniques, which do not
require the administration of intravascular radiographic contrast media. There is no need to do hemodialysis
right after the contrast medium injection as it does not reduce the risk of contrast medium induced
nephropathy. For radiographic examinations gadolinium based contrast media cannot be recommended to
avoid nephrotoxicity. Metformin should be stopped and the contrast study should be delayed for 48 hrs.
Metformin should only be restarted 48 hrs later after the examination if serum creatinine is normal.
References
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Radiology (ESUR) Contrast media induced nephrotoxicity: A consensus report. Eur Radiol 1999; 9: 1602-1613.
2. Hou SH, Bushinsky DA, Wish JB et al. Hospital acquired renal insufficiency: A prospective study. Am J Med 1983; 74: 243-248.
3. Nash K, Hafeez A, Hou S. Hospital-acquired renal insufficiency. Am J Kidney Dis 2002; 39: 930-936.
4. Solomon R. Contrast medium-induced acute renal failure. Kidney Int 1998; 53: 230-242.
5. Gruberg L, Mintz GS, Mehran R et al. The prognostic implications of further renal function deterioration with 48 h of interventional
coronary procedures in patients with pre-existent chronic renal insufficiency. J Am Coll Cardiol 2000; 36: 1542-1548.
6. McCullough PA, Wolyn R, Rocher LL et al. Acute renal failure after coronary intervention: incidence, risk factors and relationship to
mortality. Am J Med 1997; 103: 368-375.
7. Rudnik MR, Goldfarb S, Wexler L et al. Nephrotoxicity of ionic and nonionic contrast media in 1196 patients: a randomized trial.
Kidney Int 1995; 47: 254-261.
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of renal impairment. Kidney Int 1999; 55: 1878-1884.
11. Thomsen HS, Morcos SK, Members of Contrast Media Safety Committee of European Society of Urogenital Radiology (ESUR). In
which patients should serum-creatinine be measured before contrast medium administration? Eur Radiol 2005; 15; 749-754.
12. Thomsen HS. Contrast nephropathy. In: Thomsen HS, Muller RN, Mattrey RF (eds) Trends in contrast media. 1999, Berlin, Springer
Verlag, 103-116.
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119

23. Huber W, Jeschke B, Kreymann B et al. Haemodialysis of the prevention of contrast-induced nephropathy. Outcome of 31 patients
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ABSTRACTS
MEMBERS’ SESSION
MS1
In-vivo magnetic resonance imaging of magnetically labeled stem cells in kidneys after selective
intraarterial injection: initial results
Harald Ittrich 1, Friedrich Thaiss 2, Claudia Lange 3, Hannes Dahnke 4, Gerhard Adam 1, Claus Nolte-Ernsting 1
1 Department of Diagnostic and Interventional Radiology, 2 Department of Internal Medicine, Division of Nephrology and
Osteology, 3 Department of Haematology/Oncology, Bone Marrow Transplantation, University Hospital Hamburg-Eppendorf
Martinistr. 52, DE-20246 Hamburg, Germany, 4 Philips Research Laboratories – Hamburg Division Technical Systems
Roentgenstr. 24-26, DE-22335 Hamburg, Germany
OBJECTIVES: To evaluate MRI for in-vivo tracking of selectively intraarterial injected iron oxide-labeled mesenchymal stem cells
(rMSCs) in a rat model of glomerulonephritis.
MATERIAL AND METHODS: 10^6 magnetically labeled rMSC were injected in the left renal artery in rats four days after the
induction of an anti-Thy1 antibody-induced glomerulonephritis (control group: no rMSC injection). In-vivo MR Imaging and MR
Relaxometry were performed repetetivly up to day 22 using a clinical whole body 3T scanner. MRI data were correlated with kidney
histology. Statistical analyses of signal intensity (SI) changes and T2* relaxation-time in both groups were performed.
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
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
diameter) injected in abdominal aorta. Other 3 not-embolized rabbits were considered controls. Both kidneys were insonated at
baseline, and contrast-enhanced US at low transmit power (mechanical index: 0.09 - 0.12) by one sonologist who assessed on-site
RPDs dimensions and conspicuity (visual score 0 - 4). Digital cine-clips were reviewed off-site by two blinded independent readers
who assigned a confidence level (grade 1 - 5) in RPD diagnosis.
RESULTS: RPDs appeared as focal areas of absent or diminished vascularity (diameter of the smallest identified RPD = 6 mm;
median visual conspicuity score = 4) corresponding closely to renal infarctions or ischemic areas showed at macroscopic/histologic
analysis. Diagnostic confidence in RPDs improved significantly (P < 0.05) at contrast-enhanced US (area under Receiver Operating
Characteristic curve: 0.615 vs 0.972 -reader 1-; 0.720 vs 0.953 -reader 2-).
CONCLUSION: Contrast-enhanced US at low transmit power insonation was feasible in focal RPDs diagnosed in an animal model.
MS5
Doppler ultrasonography of arterial stenosis in renal transplanted patients
Gaute Hagen 1,4, Jonas Wadström 2, Anders Magnusson1; 1Department of Radiology, 2Department of Transplantation Surgery,
Uppsala University Hospital, SE-751 85 Uppsala, Sweden, 4 Department of Radiology, Sykehuset Östfold Moss, N-1535 Moss,
Norway
PURPOSE: To evaluate the accuracy of Doppler ultrasonography in the diagnosis of transplant renal artery stenosis (TRAS) or iliac
artery stenosis.
MATERIALS AND METHODS: Three-dimensional rotational angiography (3D-RA) was carried out on 55 consecutive renal
transplanted patients with suspicion of TRAS or
iliac artery stenosis. The suspicion was based on Doppler ultrasonography findings, increasing serum creatinine, hypertonia, and/or
biopsy findings indicating ischemia. The stenoses were defined by the angiographic location and when possible verified with
pressure measurement. Prior to the 3D-RA the patients were examined with Doppler ultrasonography. A significant stenosis was
suspected when the peak systolic velocity (PSV) was 2.5 m/s or more at a Doppler angle of 60° or less.
RESULTS: Doppler ultrasonography suspected stenosis in 42/55 (76%) patients; 35 with TRAS, 5 with iliac artery stenosis and 2
with both. There were no false-negative Doppler ultrasonographies, but 14 false-positive examinations, all TRAS. The sensitivity of
Doppler ultrasonography was 100%, the specificity was 48%, and the PPV was 67%.
CONCLUSION: Doppler ultrasonography is an important initial method for the evaluation of arterial stenosis in renal transplanted
patients, but an angiographic confirmation is still required.
MS6
Catheter-based optical coherence tomography of the porcine ureter ex vivo: morphometric comparison with histology
U.L. Mueller-Lisse, O. A. Meissner, M. Bauer, M. Jaeger, F. Roggel, G. Babaryka, M. Reiser, U.G. Mueller-Lisse;
Klinik und Poliklinik für Urologie, Institut für Pathologie und Institut für Klinische Radiologie der Ludwig-Maximilians-Universität,
München
PURPOSE: Based on near-infrared light (1350 nm), which is emitted from a catheter-mounted optical fiber, intraluminal optical
coherence tomography (OCT) provides cross-sectional images of vessels and hollow organs, with a lateral resolution of 4-20 ľm.
We compared width estimates of different ureteral wall layers in OCT images with histologic sections of porcine ureters ex vivo.
MATERIALS AND METHODS: The OCT probe (diameter, 0.014 inch, LightLab Inc., Westford, MA) was introduced into each of 6
porcine ureter specimens ex vivo. Ureters were dilated with normal saline solution to approximately 4 mm. Single-slice crosssectional
OCT images and H&E-stained histologic sections were obtained at marked positions. Two independent observers (O1,
O2) each determined width of ureteral wall layers (urothelium, lamina propria, muscle layer) by means of OCT software and light
microscopy, respectively. At least 10 different positions per specimen were evaluated.
RESULTS: OCT distinguished ureteral wall layers in all specimens. Means +/- standard deviations of measurements (in ľm) by
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
lamina propria, and 310+/-90/540+/-120 vs. 220+/-30/310+/-110 for muscle layer, respectively.
CONCLUSION: Intraluminal OCT demonstrates different ureteral wall layers with width estimates very similar to width estimates in
histologic sections. Overestimation by OCT may be due to higher spatial resolution of light microscopy and tissue shrinkage in
histologic sections.
MS7
Assessment of diagnostic confidence in renal malignancies diagnosed at contrast-enhanced US
Emilio Quaia, Alessandro Palumbo, Stefania Rossi, Maria Cova / Department of Radiology - Cattinara Hospital,
University of Trieste (Italy)
PURPOSE: To assess diagnostic confidence in renal malignancies diagnosed at contrast-enhanced US.
MATERIALS AND METHODS: A series of solid (46 renal cell carcinomas -RCCs-, 5 renal metastases, 4 embryonal matanephric
adenomas -EMAs-, 14 angiomyolipomas -AMLs- and 1 oncocytoma) or cystic (15 cystic RCCs, 2 multilocular cystic nephromas, 2
inflammatory and 4 haemorragic cysts) renal tumours < 4 cm, in 93 consecutive patients (55 male and 38 female, age 65 +/- 15
years), were scanned after microbubble injection. Two independent blinded readers not involved in scanning retrospectively
expressed a malignant or benign diagnosis according to standard criteria. Histology (n=75) or multimodality imaging modalities
(n=18 tumours) were reference procedures.
RESULTS: Solid tumours revealed diffuse homogeneous (17 RCCs, oncocytoma and 4 AMLs) or heterogeneous (29 RCCs and
EMAs), dotted (10 AMLs) or absent (metastases) enhancement. Cystic RCCs revealed peripheral rim-like (n=3), nodular (n=3) or
diffuse nodular and septal (n=9) enhancement, while benign cystic renal tumours revealed peripheral rim-like (multilocular cystic
nephromas and inflammatory cysts) or absent (haemorragic cysts) enhancement. Diagnostic confidence in malignancy diagnosis
improved significantly (P

CONTENT: The purpose of our study was to evaluate the different variables at dynamic MRI before and after kidney drainage in
cases of acute upper urinary tract obstruction.
M.M: Thirty patients with acute upper urinary tract obstruction; 5 bilateral and 25 solitary functioning kidneys (17 left & 8 right). Their
age range 26-74 yrs, the mean age 53 + 12 yrs. Dynamic study for the kidney using gradient echo T1, we assessed the kidney
size, parenchymal SI, corticomedullary differentiation, cortico-medullary crossing time & time to peak. All these variables were
evaluated before & after kidney drainage.
RESULTS: Among the 35 units, there was no significant change in kidney size, the parenchymal SI was increased in 30 units, in 3
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
after drainage. There was CM crossing in 28 with improved curves after drainage while in the remaining 7 there was crossing in 4
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
each unit was 71.6 + 118 sec before & 67 + 79 sec after (r = .76).
CONCLUSION: Dynamic MRI could be used as an on-invasive technique in diagnosis of acute upper urinary tract obstruction.
MS9
Delineation of upper urinary tract segments at low-dose multidetector CT urography: retrospective comparison with a
standard protocol
Mueller-Lisse UG, Meindl T, Coppenrath E, Mueller-Lisse UL, Degenhardt C, Khalil R, Reiser MF
Depts. of Radiology and Urology, University of Munich, Germany
PURPOSE: CT urography (CTU), as an add-on to contrast-enhanced CT of the abdomen and pelvis, may replace excretory
urography in patients with pelvic tumors. However, radiation exposure is a concern. We retrospectively compared upper urinary
tract (UUT) delineation in low-dose and standard CTU.
MATERIALS AND METHODS: CTU (1-2 phases) was obtained with 120 KV, 4x2.5 mm collimation, and pitch 0.875 after i.v.
injection of 120 ml of non-ionic contrast media with 300 mg of iodine/ml with standard (14 patients, n=116 UUT segments, average
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
minutes) protocols. UUT segments included intrarenal collecting system (IRCS), upper, middle, and lower ureter (UU,MU,LU). Two
independent readers (R1,R2) graded UUT segment delineation as 1-absent, 2-partial, 3-complete (noisy margins), 4-complete and
clear. Chi square (X2) statistics were calculated for grades 1-2 vs. 3-4 (delineates course of UUT, may locate obstruction/dilation)
and 1-3 vs. 4 (may locate intraluminal lesions).
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,
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-
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
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
seven renal cancers were interpreted as “most probably” or definitely renal cyst, including the largest observed renal cancer that
had 9 cm in diameter and was cleary hypervascular on color and power Doppler. In patients with wrong initial diagnosis
examination was performed most commonly by general practitioners (20), but also by nephrologists (4), urologists (4),
gastroenterologists (3), abdominal surgeons (2), and radiologists (2). The diagnosis was delayed up to one year.
CONCLUSION: Non-visualization or erroneous characterization of solid renal lesions on US is very common, particularly when
examinations are performed by insufficiently trained physicians and non-radiologists. Good education in US and experience are
essential for proper visualization and characterization of renal tumors.
MS12
Diagnosis of upper tract transitional cell carcinoma (TCC) with a single phase multidetector CT urography
F.Cornud, M.Bienvenu, H.Guerini, X. Poittevin, A.ChevrotT
PURPOSE: to describe upper tract TCC features on a single phase MDCTU with split bolus injection and hyperdiuresis.
MATERIALS AND METHODS: 29 patients (mean age: 69, range 56-88, 23 men) with a histologically proven TCC were reviewed. A
3 phase protocol with hyperdiuresis (furosemide 20mg) was used in all patients (unenhanced, corticomedullary and combined
nephrographic-excretory phase after reinjection of 50 ml of contrast medium). Ability of the third phase to detect the tumor and
assess pT stage was investigated.
RESULTS: 17 lesions were located in the pelvicaliceal system and 12 in the ureter. Lesions presented as a non obstructive filling
defect in 12 cases, an obstructive mass in 7 cases and with an infiltrative pattern in 10 cases. On the combined nephrographicexcretory
phase, all tumors could be detected. Tumor size was overestimated in one case due to the presence of a clot abutting the
tumor.
Tumor enhancement was obvious in all obstructive masses and in 9/10 infiltrative tumors.
CONCLUSION: Upper tract TCC’s can be accurately detected on a single phase MDCTU with split bolus injection and induction of
a hyperdiuresis. The value of a one phase MDCTU should be assessed to reduce irradiation when investigating the urinary tract
with MDCTU.
MS13
Does a limited CT Urography (CTU) offer important additional information in patients with haematuria who had normal
IVU, Ultrasound and Flexible Cystoscopy?
H S Ganesh, F Salim, S K Moecos; Department of Diagnostic Imaging,Central Sheffield Teaching Hospitals NHS Foundation Trust,
Herries Road, Sheffield, S5 7AU,UK
OBJECTIVE: Evaluating the impact of of CTU in patients with haematuria and normal IVU, ultrasound and flexible cystoscopy.
PATIENTS AND METHODS: A total of 34 patients (23males, 11 females, mean age 58.6, range 29-87 years) with negative
investigations for haematuria underwent CTU using a multislice CT scanner (4 slice). A precontrast scan of the kidneys was
performed followed by a scan of the whole abdomen 5 minutes after intravenous injection of 50 mls of non ionic contrast medium
(300mg iodine/ml) and 10 mg of furosemide. The scanning parameters were 2.5mmx4 collimation, 120kVP, 80mAs. Contiguous
axial images(5mm slice thickness), coronal images (3mm slice thickness using MIP) and a thick coronal slab (80mm slice thickness
using MIP) were obtained. The scans were assessed independently by two uroradiologists.
RESULTS: Twenty scans (58%) were reported as normal and 14 (42%) abnormal [small renal calculi in 8 patients(23%), simple
cysts(4 patients), high density cyst(1 patient)and previous partial nephrectomy(1 patient)]. Good agreement was observed between
the two radiologists (K>0.65). The diagnostic quality of the examinations were rated as either excellent or very good except in three
examinations which reported as satisfactory by one uroradiologist.
CONCLUSION: Small renal calculi not detected by standard imaging techniques were the only important abnormality detected in
this group of patients.
MS14
Ferumoxtran-10 enhanced MR imaging in detection of metastases out of the surgical view in prostate cancer
R.A.M. Heesakkers, J.A. Witjes, C.A. Hulsbergen- van de Kaa, J.O. Barentsz; Radboud University Nijmegen medical centre
PURPOSE: To evaluate the diagnostic value of Ferumoxtran-10 enhanced MR imaging in the detection of lymph node metastases
out of the surgical view in patients with prostate cancer.
MATERIAL AND METHODS: 150 consecutive patients with prostate cancer were enrolled in this study. At 1.5T, T1 and T2*
weighted MR images of the obturator area were obtained, 24 hours after Ferumoxtran-10 administration. The MR examinations
were evaluated by one experienced reader.
Lymph node metastases were confirmed by lymph node dissection, follow-up scan or CT-guided lymph node biopsy.
RESULTS: Thirty-one out of 150 patients had positive lymph nodes confirmed by histopathology. Of these 31 patients, 16 patients
had positive lymph nodes only outside, 8 in and outside, and 6 inside the surgical view (e.g. obturator area), respectively. Twentyfive
out of 31 were detected using USPIO enhanced MR imaging (X out of X outside the surgical view).
CONCLUSION: Ferumoxtran-10 enhanced MR imaging may be used to guide the urologist in selective dissecting of positive lymph
nodes.
MS15
IMRT boost planning on dominant intraprostatic lesion by means of gold marker-based 3D fusion of CT, 1H spectroscopic
and dynamic contrast-enhanced MR imaging.
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
Kollenburg, Henkjan J. Huisman, J. Alfred Witjes, Jan Willem Leer, Andries G. Visser, Jelle O. Barentsz;
Dept of radiology, urology and radiotherapy, university medical Center nijmegen, The Netherlands
PURPOSE: To demonstrate the feasibility of the fusion of functional MR imaging techniques with CT using gold markers as
fiducials, to define biological target volume for high-dose dominant intraprostatic lesion (DIL) boosting with intensity modulated
radiotherapy (IMRT).
MATERIAL AND METHODS: Seven patients with biopsy-proven, localized prostate cancer enrolled in this study. Four fine gold
markers were inserted via trans-rectal ultrasound. Patients underwent both CT and MR imaging on the same day. The planning CT
scan was obtained at 3-mm slice thickness using an endorectal balloon. Endorectal MR imaging was performed obtaining T2-
124

weigthed, spectroscopic and dynamic contrast-enhanced MR imaging. CT and MR imaging sets were aligned by registration of the
gold markers. The functional MR data were fused with the CT data. An experienced radiologist and radiotherapist evaluated all
data.
RESULTS: In all seven patients a DIL could be determined with combined functional imaging techniques. The DIL volumes ranged
between 1.1-8.5 cc. IMRT treatment planning could be performed in all patients. The dose distribution of the inner rectal wall
circumference for the IMRT plans
clearly showed an improved pattern of dose exposure to the rectal wall mucosa.
CONCLUSION: Functional MR imaging can be used to accurately define the DIL for boosting with IMRT.
MS16
The additive effect of contrast agent administration in transrectal ultrasound staging of prostate cancer
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,
2 J. Alfred Witjes, 1 Johan G. Blickman, 1 Jelle O. Barentsz; Department of Radiology 1, Department of Urology 2, Department of
Pathology 3, Radboud University Nijmegen Medical Centre
URPOSE: To assess the value of contrast-enhanced over non-enhanced transrectal ultrasound (TRUS) staging of prostate cancer
(PC).
MATERIALS AND METHODS: From February 2004 to February 2005, 50 consecutive patients with biopsy-proven and clinically
localized PC underwent TRUS prior to radical prostatectomy. Axial imaging of the whole prostate was performed using gray-scale,
colour and power Doppler imaging. Subsequently, during a slow (1ml/min) intravenous infusion of Sonovue® another set of power
Doppler images was obtained.
Prospectively, two readers (one with one year of TRUS experience and one without prior experience) independently reviewed all
imaging and determined the disease stage as stage T2 or T3 disease on a 5-point probability scale for each set of imaging. Wholemount
section histopathology was the standard of reference.
RESULTS: For the experienced reader staging sensitivity and specificity at gray-scale imaging were 25% (3/12) and 95% (36/38),
respectively. Contrast-enhanced power Doppler imaging increased sensitivity to 58% (7/12) with a specificity of 79% (30/38).
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
(TP), sharpness-of-the-bolus transit, and area-under-the-curve (AUC) were considered for further analysis.
RESULTS: After tadalafil administration the enhancement peak and AUC increased significantly (p= 1.3x density of peripheral zone)
differentiated central gland and peripheral zone in 51 prostates (61%).
CONCLUSIONS: pvMDCT is capable of distinguishing central gland and peripheral zone of normal prostates. Comparison of
respective CT densities is superior to visual analysis of pvMDCT images. However, results imply that pvMDCT would contribute to
prostate cancer localization by means of PET-CT only in a subset of patients.
MS20
The Urethral Support System as Defined By Phased-Array MRI with Cadaveric Dissection and Histological Correlation in
Nulliparous Female
Rania F. El Sayed*, Medhat Morsi **Sahar El Mashed *, Mohamed S. Abd El Azim ***.
Departments of Radiology *, Anatomy **. Urology ***, Faculty of Medicine, Kaser El Ainy Hospitals, Cairo University, Egypt.
PURPOSE: To determine which element of the female urethral support structures is found on anatomic dissection and could be
visualized on MRI performed without an endovaginal coil, plus histological analysis of each structure.
MATERIALS AND METHODS: Volunteer study included 17 healthy nulliparous volunteers. MRI was done using 1.5-T (Gyroscan
Philips). T2WI TSE were acquired in the axial, sagittal, and coronal planes with a slice thickness 5mm and slice gap 0.7 mm,
TR/TE 5000/132, Field of view 240-260.
Cadaveric Study: Dissection of 6 cadavers was done in an experimental way to explore the periurethral supporting structures. The
ligaments were labeled by a marker for their identification, digital images were taken, and MR imaging was performed. Then
comparison between the dissected specimen, their MRI images and the MRI of the control subjects was done. Histological study:
Microscopic analysis was performed by an experienced pathologist.
RESULTS: Guided by the marker placed on the different urethral supporting ligaments in the cadavers, we identified different
orientation of two of the urethral supporting ligaments (pubourethral, uretheropelvic), to our knowledge those orientations haven’t
been described previously. Applying the grid system on the MR images of the control group , the most fixed ligaments that could
be visualized were the periurethral ligament, followed by the uretheropelvic ligament.
CONCLUSION: Our MRI findings suggest that MRI yielded detailed information on the urethral support system.
SCIENTIFIC SESSIONS
SS1
Multi-detector row CT urography in the investigation of painless hematuria
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, D. Giannakis2, P. Tzoumis2, D. Dristiliaris3, N. Sofikitis2, S. C. Efremidis1.
1Department of Clinical Radiology 2Department of Urology 3Department of Medical Physics University Hospital of Ioannina,
GREECE
PURPOSE: To assess the role of multi-detector row CT (MDCT) urography, with a 16-row CT scanner in the evaluation of patients
presenting with painless hematuria.
MATERIALS AND METHODS: The study included seventy-five patients referred for painless hematuria. Examinations were
performed on a 16-row CT scanner and a three-phase protocol was used. Unenhanced images were obtained with a detector
configuration of 16 C 1.5 mm and pitch of 1.2. After intravenous administration of iodinated contrast material and 250 ml of saline
solution nephrographic-phase and excretory-phase images were obtained, with collimation thickness of 16 X 0.75 mm and pitch of
1.2. Axial and coronal reformatted images were evaluated. Three- dimensional reformations of the excretory-phase data was
performed using the volume-rendering technique. The standard of reference included clinical and imaging follow- up, cystoscopic
and/or ureteroscopic findings, surgical and histologic findings.
RESULTS: MDCT urography demonstrated a sensitivity of 96%, a specificity of 89%, a positive predictive value of 96% and a
negative predictive value of 89% in the identification of the cause of hematuria, when compared to the methods used as reference.
CONCLUSION: A hematuria CT protocol based on 16-slice multidetector technology is highly accurate in detecting and excluding
significant causes for painless hematuria.
SS2
Multiphase Multidetector-Row CT (MDCT) of Transitional Cell Carcinoma of the Renal Pelvis and the Ureter: Improved
Detection, Diagnosis and Staging
126

Gerald A. Fritz, Helmut Schoellnast, Hannes A. Deutschmann, Martin Wehrschuetz, Manfred Tillich Department of Radiology Univ.
Hospital Graz, Austria
PURPOSE: To evaluate the potential of multiphase multidetector CT (MDCT) in detection, diagnosis and staging of transitional cell
carcinomas (TCC) of the upper urinary tract.
MATERIALS AND METHODS: We performed a retrospective chart review of 36 consecutive patients with suspect urothelial lesions
of the upper urinary tract. In all patients the urinary tract was examined using MDCT performing unenhanced and contrast
enhanced scans during the cortical nephrographic, tubular nephrographic and pyelographic phase. The attenuation of the lesions
was documented in Hounsfield units (HU). Tumor staging was performed according to TNM-classification. MDCT and
histopathological findings were correlated.
RESULTS: Histopathological examination revealed 33 TCC (13 renal, 20 ureteral) and 3 patients with inflammatory changes. All
TCC were visible on cortical nephrographic and tubular nephrographic phase scans. TCC showed a mean attenuation of 77.8 ±18.5
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
was a significant difference in mean attenuation between between neoplastic and inflammatory changes in the tubular
nephrographic phase (p = 0.002). A differentiation between organ confined stages (0 - II) was not possible with MDCT. CT correctly
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.
Overall, CT was accurate in predicting pathologic TNM stage in 28 / 33 patients (84.8 %).
CONCLUSION: MDCT with its high spatial resolution is an accurate tool for diagnosis and staging of TCC. Significant higher
attenuation of inflammatory changes in tubular nephrographic phase was seen.
SS3
Patients at high risk of upper tract urothelial cancer: evaluation of hydronephrosis using high-resolution magnetic
resonance urography
Rohit Chahal, Kathryn Taylor, Ian Eardley, Stuart N Lloyd, John A Spencer, St James's University Hospital, Leeds LS9 7TF, UK
PURPOSE: To assess the potential of magnetic resonance urography (MRU) in the evaluation of hydronephrosis not explained by
standard investigation in patients at high risk of upper tract urothelial cancer.
MATERIALS AND METHOD: 23 consecutive patients in a specialist urological unit with unexplained hydronephrosis prospectively
underwent MRU which comprised overview heavily T2-weighted MR urographic images followed by focussed high-resolution TSE
T2-weighted sequences obtained in an axial and coronal oblique plane through the level of urinary obstruction. All were at high risk
of urothelial cancer and had either contraindications to or problems with standard investigations including poor contrast excretion
due to obstruction or renal failure, failed ureteric cannulation or contrast allergy.
RESULTS: In 23 patients, 8 ureteric TCCs and 5 renal pelvic TCCs (two bilateral) were diagnosed by MR and confirmed
histologically. In a further 5 patients benign causes for the hydronephrosis were found. No intrinsic or extrinsic pathology was
demonstrable in 5 patients whose imaging findings were stable over one year of follow up.
CONCLUSION: MRU is a valuable non-invasive investigation in this group of patients where routine investigation had failed to
provide clinically important information. Focussed high- resolution T2-weighted images were reliable in the diagnosis of ureteric and
renal pelvic TCCs and were valuable in excluding these and other mass lesions as the cause of hydronephrosis.
SS4
Pheochromocytoma: a retrospective review of 27 cases with their histopathologic correlation
Dogra VS, Bhatt S, Novak R, Martin C, MacLennan G Case Western Reserve University Cleveland, OH USA
PURPOSE: To assess cross – sectional imaging features of pheochromocytoma with histopathologic correlation and clinical
presentation.
MATERIAL AND METHODS: A retrospective review of a pathological data base from 1995 to 2005 was performed. In total, 27
cases of histopathologically confirmed cases of pheochromocytoma were identified in 11 females and 16 males, age range (7- 73;
mean 41.8±23 yrs). Of these 27 cases, 21 had imaging studies performed in our institution. Imaging appearances of these cases
were compared with their histopathologic features, and co-related with their clinical presentations and their laboratory test values.
All the 27 cases underwent surgical excision of the pheochromocytoma; prior biopsy was performed only in one patient. Because of
the small number of patients and the non-normal distribution of vanillylmandelic acid (VMA) values, the Mann-Whitney U test was
used to test differences between groups.
RESULTS: Following observations were made in this retrospective study of 27 surgically confirmed cases of pheochromocytoma:
Unilateral Rt- 15 Lt-7 Bilateral 1 Extra-adrenal 3 Associated with hereditary syndromes 3 Malignant 3 Recurrent
Pheochromocytoma 2 Children ( < 18 years) 6 In one case, side could not be determined. 6 of 27 patients = 22% were below the
age of 18 years. Average size of the lesion in adrenal pheochromocytomas (19/21) was 5.6cm. ( Including one bilateral). Average
size of the lesion in extra adrenal pheochromocytomas (3/21) was 2.46 cm. Malignant nature of pheochromocytoma was
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
Ultrasound and 5/21 had Radionuclide study. MRI features of low and high signal intensities on both T1 and T2 weighted images,
was the commonest feature due to presence of both hemorrhage and necrosis, observed in 7/9 MRI studies Ultrasound was not
helpful in making a diagnosis of pheochromocytoma, but an adrenal mass was detected on ultrasound in 4 of the above cases, and
showed a solid appearing mass lesion in 3 cases, and central cystic change in 1 case, with increased peripheral vascularity in 2
cases. Increased uptake of I-131 or I-123 MIBG was observed in all 5 cases in which MIBG study was performed. Clinical
presentation and laboratory values of VMA of all these patients were retrospectively studied and correlated with their imaging
findings and their attributes. VMA range was observed to be (5.1-76.8 mg/24hr.) [Normal VMA levels - < 6.8mg/24 hrs]. Average
VMA value was 22.8±19.4 mg/24 hr. Average VMA in malignant pheochromocytomas (3/21) was observed to be 48.2
mg/24hr.Average VMA in non-malignant pheochromocytomas (13/21) was observed to be 20.11 mg/24hr. (In 5/21 cases, VMA
could not be measured due to inappropriate collection of urine sample).VMA values were not found to be different between adrenal
and extra-adrenal pheochromocytomas (U= 29.0, p = 0.58). In this group of patients, 15/21 presented with hypertension and 6/21
did not, when hypertension is defined as 160/90 mm/Hg. There was no difference in VMA values between hypertensive and nonhypertensive
individuals in this study (U=27.0, p=0.46).
CONCLUSION Low and high signal intensities on both T1 and T2 weighted images is commonest MR finding. Pheochromocytomas
had a much higher unilateral occurrence (right > left), than bilateral occurrence. Extra-adrenal pheochromocytomas were smaller in
size than adrenal pheochromocytomas.
127

SS5
Evaluation of focal renal lesions with contrast enhanced ultrasonography (CEUS) using a new microbubble contrast agent
(SonoVue®)
Pallwein L.1, Frauscher F.1, Neururer R.2, Georg B.2, Klauser A.2 , Gradl H1, Schurich M1.; 1Radiology II, Innsbruck, Austria,
2Urology, Innsbruck, Austria
PURPOSE: To assess the value of contrast enhanced ultrasonography (CEUS) with a new microbubble contrast agent
(SonoVue®; Bracco) in differential diagnosis and delineation of focal renal lesions
MATERIALS AND METHODS: 23 focal renal lesions were examined prospectively with CEUS using SonoVue® (Bracco, Italy)
performing bolus injection (2.5 ml) and an Acuson Sequoia, Mountain View, CA (4Hz, low MI =0.3; pulse- inversion imaging).
Diagnosis was based on CT and/or Histology (renal cell carcinoma (RCC) n=11; transitional cell cancer (TCC) n=2, angiosarcoma
n=1; cystic lesion Bosniak II-IV n=5; hypertrophic columna n=1; regenerating nodule n=3)
RESULTS: RCCs showed a high contrast agent uptake during arterial phase and a contrast agent "wash out" during venous phase.
TCCs demonstrated a low, increasing enhancement during arterial and venous phase. Benign lesions (hypertrophic columna and
regenerating nodule) showed contrast enhancement equal to the renal cortex and no wash out. Bosniak II cystic lesions had no
contrast agent uptake. These enhancement patterns were associated with the either benign or malign nature of the lesion (p=0.02;
Chi Quadrat test).
CONCLUSION: CEUS with SonoVue® improves lesion delineation and lesion detection rate of small renal masses. The
enhancement pattern of a lesion yielded important information for the differential diagnosis between benign and malign focal renal
lesions.
SS6
Multi-detector row CT cystoscopy in the assessment of urinary bladder tumors
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, P. Champilomatis2, P. Tzoumis2, N. Chatziparaskevas1, N. Sofikitis2, S. C.
Efremidis1; 1Department of Clinical Radiology, 2Department of Urology, University Hospital of Ioannina, GREECE.
PURPOSE: To assess the role of multi-detector row CT (MDCT) cystoscopy, with a 16-row scanner in the detection of urinary
bladder tumors.
MATERIALS AND METHODS: The study included thirty-eight patients with urinary bladder tumors diagnosed on conventional
cystoscopy. The patients were examined after distention of the urinary bladder with room air. We used a detector configuration of
16 X 0.75 and a pitch of 1.2. Virtual images were created using volume-rendered algorithms. The lesions were studied on
transverse tomographic slices, on multiplanar reformations and on virtual images, using conventional cystoscopy as the gold
standard.
RESULTS: MDCT cystoscopy depicted 52 lesions in 28 patients. Forty-eight lesions revealed on CT cystoscopy were true-positive
findings and four were false-positive. We had one false-negative case, in a patient with a tumor involving the prostatic urethra. On
CT cystoscopy 19 lesions smaller than 0.5 cm were identified. The sensitivity, specificity, positive predictive value and negative
predictive value of MDCT cystoscopy for the detection of the urinary bladder tumors were 98 %, 69 %, 92 % and 90 %,
respectively.
CONCLUSION: MDCT cystoscopy is an effective diagnostic modality in the evaluation of urinary bladder neoplasms, capable in
identifying lesions smaller than 0.5 cm.
SS7
Preoperative MSCT imaging of venous spread of renal cell carcinoma (RCC)
Stern-Padovan R, Perkov D, Smiljanic R, Oberman B, Lusic M, Marinic J.
Clinical Institute of Diagnostic and Interventional Radiology, Clinical Hospital Center Zagreb, University of Zagreb, School of
Medicine, Zagreb, Croatia
PURPOSE: To assess MSCT in the preoperative evaluation of RCC, with special consideration of the presence and extent of a
thrombus in inferior vena cava (IVC), hepatic veins and right atrium.
MATERIALS AND METHODS: Multiphase MSCT examinations performed during 3-year period in patients with RCC and the tumor
spread into the renal vein and IVC (Robson IIIa; TNM T3b/T3c) were retrospectively analyzed.
RESULTS: MSCT has shown to be highly accurate in the diagnosis of spread of RCC into the IVC, hepatic veins and right atrium.
Venous extension is optimally shown during the corticomedullary phase of enhancement, with a combination of axial images and
coronal, sagittal and/or multiplanar reconstruction. The most specific sign of venous extension is the presence of a low-attenuation
filling defect within the vein. The level of venous involvment, the distal and proximal extension of the thrombus and infiltration of the
venous wall, including IVC, hepatic veins and right atrium, dictates the surgical approach.
CONCLUSION: An accurate preoperative evaluation of involvement of IVC, hepatic veins and right atrium in patients with RCC is
crucial. MSCT is presently the best technique for diagnosing the RCC and the tumor spread into the IVC, hepatic veins and right
atrium, as well as for planing the surgical procedure.
SS8
Evaluation of Varicocele Incidence of Paraplegic Patients by Colour Doppler Ultrasonography
Alparslan UNSAL*, Bilge YILMAZ**, Ahmet T. TURGUT***, Can Z. KARAMAN*, Ridvan ALACA**
* Adnan Menderes University Faculty of Medicine Department of Radiology, AYDIN
** Turkish Armed Forced Rehabilitation & Care Center Department of Physical Medicine and Rehabilitation, ANKARA
*** S.B. Ankara Training & Research Hospital Department of Radiology, ANKARA
PURPOSE: To evaluate the varicocele incidence of patients with spinal cord injury by color Doppler ultrasonography.
MATERIALS AND METHODS: Sixty patients {48 patients with upper motor neuron injury (U-MNI) & 12 patients with lower-MNI}
with traumatic spinal cord injury and age matched 48 healthy volunteers were enrolled in this prospective study. Testis volumes and
varicocele grades were determined. Presence of varicocele was also classified according to clinical significance.
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
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,
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
difference was statistically significant (p=0.000, p=0.007, respectively).
128

CONCLUSION: Clinical varicocele incidence of U-MNI patients, who have spastic paralysis of abdominal muscles, is similar to the
control group. This finding inspires that intra-abdominal pressure via normal to increased abdominal muscle tonus may have a role
in the varicocele etiology, besides the classical factors. Absence of clinical varicocele in L-MNI patients, who have flaccid paralysis
of the same muscle groups, supports this observation.
SS9
Resistivity and Pulsatility Index Alteration in Subcapsular Branches of Testicular Artery: Indicator of Impaired Testicular
Microcirculation in Clinical Varicocele?
Alparslan UNSAL*, Ahmet T. TURGUT**, Fusun TASKIN*, Can Z. KARAMAN*
* Adnan Menderes University Faculty of Medicine Department of Radiology, AYDIN
** S.B. Ankara Training & Research Hospital Department of Radiology, ANKARA
PURPOSE: To compare the testicular artery spectral Doppler parameters of the subclinical and clinical varicocele cases.
MATERIALS AND METHODS: One hundred and seven volunteers were enrolled in this prospective study. Testis volumes and
varicocele grades according to clinical significance were determined. Spectral Doppler analyses of testicular arteries {peaksystolic/end-diastolic
velocity, resistivity/pulsatility index (RI/PI)} were obtained from subcapsular and central branches.
RESULTS: Average testis volumes of subclinical (n=86, 16.41 ± 4.99 ml) and clinical varicocele (n=21, 16.26 ± 4.19 ml) groups
were comparable (p=0.892). No statistically significant difference was found between the Doppler parameters obtained from the
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
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),
respectively}.
CONCLUSION: Increased resistivity and pulsatility indices of subcapsular testicular arterial branches on spectral Doppler
examination can be an indicator of impaired testicular microcirculation among the patients with clinical varicocele. Further studies
aimed to estimate cut-off values for these indices and to elucidate any effect on fertility by means of correlations with the sperm
parameters are needed.
SS10
The reliability of ultrasonography in the evaluation of acute scrotal pain
Lyssiotis Ph.*, Constantinidis F.*, Alivisatos G.**, Anastopoulos I*, Liakouras Ch.**, Tsines G.*, Tavernaraki K.*, Malahias G.*
*Radiology and U/S department; **2nd Urology Department, Athens Medical School, Sismanoglion General Hospital, Athens,
Greece
PURPOSE: The aim of this work is the investigation of the reliability of U/S examination in the evaluation of patients with acute
scrotal pain, a condition that often requires immediate surgical treatment in order to avoid irreversible testicular damage.
MATERIALS AND METHODS: The study includes 126 individuals (18-74 years old) admitted to the Urologic Outpatient Department
claiming painful scrotal swelling associated with other local or general symptoms. All the above mentioned persons underwent a
gray-scale and colour Doppler U/S examination for the estimation of the scrotal and adjacent tissues' ecomorphology and
vascularity.
RESULTS: The U/S examination yielded normal findings in 88 cases (70%) and pathologic in 38 cases (30%) including:
Torsion (2 cases), Testicular trauma (1 case), Inflammatory desease (35 cases)
CONCLUSION: Ultrasonography is a simple, cost-effective, harmless and non-invasive reliable method for the evaluation of the
acute scrotum. Other diagnostic imaging methods should be considered only when the sonographic findings are in contrast with the
clinical examinations' results.
SS11
Chronic constipation is a significant factor for the etiopathogenesis of varicocele
Ahmet Tuncay Turgut*, Eriz Ozden**, Pinar Kosar*, Ugur Kosar*, Basak Cakal***Ayhan Karabulut****.
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey
**Department of Urology, University of Ankara, School of Medicine, Ankara, Turkey
***Department of Gastroenterology, Yuksek Ihtisas Hospital, The Ministry of Health, Ankara, Turkey
****Department of Urology, Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey
PURPOSE: To determine the role of chronic constipation for the etiopathogenesis of varicocele.
MATERIALS AND METHODS: Group 1 included 25 male patients with chronic constipation with mean duration of 17.0±20.3
(range, 3-96) months whereas group 2 included 26 males without any complaint associated with constipation. All subjects were
examined clinically and by scrotal US. For the plexus panpiriformis (PP) veins mean diameter exceeding 2 mm and reflux with a
duration of more than 1 second were accepted suggestive for varicocele.
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).
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
(p

(95 KUUs) with Direct Radionuclide Cystography (DRNC) at the same session.For the statistical analysis we used Mc Nemar’s, k-
coefficient and T-student’s tests.
RESULTS: VUS, VCUG and DRNC detected reflux in 149/393 (38%), 57/298(19%)and 26/95 KUUs (27%)
respectively.Concordance in findings regarding the presence of reflux between VUS and VCUG was found in
251/298KUUs(84%)and between VUS and DRNC in 69/95KUUs (72%). Thirty-eight out of the total 97 refluxing KUUs (40%)were
depicted only by VUS when compared to VCUG.Reflux was detected only by VCUG in 7KUUs. Besides, VUS only disclosed reflux
in 24 out of the totally of 43 refluxing KUUs(55%)and missed no refluxing KUU compared to DRNC. The difference in the detection
rate of reflux was very significant.
SS13
Voiding Urosonography combined with Fluoroscopic Voiding Cystourethrography in the diagnosis of reflux: Does the
order matter?
A. Anthopoulou, F. Papadopoulou, J. Tzovara, E. Siomou, E. Arkoumani, F. Katzioti, S. Efremidis/ Ioannina, Greece
PURPOSE: Diagnostic imaging of reflux encompasses fluoroscopic-voiding-cystourethrography (VCUG) and contrast-enhancedvoiding-urosonography-harmonic-imaging
(CE VUS HI). Many studies show a higher sensitivity of VUS over VCUG due to VUS
usually proceeding VCUG when performed at the same session. The purpose of our study is to assess if the order of the
examination affects the detection of reflux.
MATERIALS AND METHODS: Two-hundred-and two children with 402 kidney-ureter-units (KUU) were studied for possible reflux.
In all children, VUS with 1-2ml of 2 nd generation contrast-agent (SonoVue) and VCUG with the standard technique were performed.
In group-A (108 children, 214 KUU) VCUG proceeded VUS, while in group-B (94 children, 188 KUU) the sequence was reversed.
For statistical analysis we used McNemar’s, k-oefficient and T-student’s tests.
RESULTS: In group-A VUS and VCUG revealed reflux in 65 (30,4%) and 41(19,2%) KUUs respectively. In group-B VUS and
VCUG depicted 75 (39,9%) and 43 (22,8%) refluxing KUUs respectively. Concordance of findings regarding the presence of reflux
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
group-A VUS depicted 29/70 (41,4%) more refluxing KUUs and missed 5/70 (0,07%) compared to VCUG. In group-B VUS
disclosed VUR in 33/76(43,4%) more KUUs and missed 1/76 (0,01) refluxing KUUs. No significant difference was found between
group-A and B in the detection of reflux by the two modalities.
CONCLUSION: The order of the examination does not influence the detection of reflux by VUS and VCUG.
SS14
Effect of premicturitional bladder volume on accuracy of postvoid residual urine volume measurements; Bladder fullness
rate is of great importance for preventing false positive residue diagnosis
Eriz Özden, Ahmet Tuncay Turgut*, Çađatay Göđüţ, Uđur Koţar*, Sümer Baltacý
Departmeny of Urology, University of Ankara, School of Medicine, Ankara, Turkey
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara, Turkey
PURPOSE: To evaluate the effect of premicturitional bladder volume (V1) on postvoid residual urine (V2) measurement and assess
the ideal V1 for an accurate V2 determination.
MATERIALS AND METHODS: 25 healthy young men without any urinary symptoms comprised the study group. Measurements by
transabdominal ultrasonography (TAUS) for V1 and V2 were performed for each subject on three different phases –each preceded
by oral intake of 1000cc of water- which were accompanied by the “mild”, “moderate” and “urgent” sensations of micturation,
respectively.
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
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
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
first two phases. No patient with V1 under 540 cc had V2 above 50 cc.
CONCLUSION: V2 measurements with an uncomfortably full bladder cause high pathologic residue values even in healthy men.
We strongly advise to perform V1 measurement of bladder by TAUS and not to measure V2 if V1 is above 540 cc.
SS15
SS16
From IVU to Unenhanced CT: Modernising the Imaging of Acute Renal Colic
Arvind Pallan, J. Graham Young, Paul Crowe, Rajesh Patel, Linda Freeman, Sean Morris Birmingham Heartlands Hospital
Bordesley Green East, Birmingham B9 5SS
PURPOSE: Uncontrasted CT is the most sensitive investigation for detecting calculi in patients presenting with suspected renal
colic. Its introduction in the UK has been hampered by perceived limitations in CT capacity and concerns regarding radiation dose.
We received funding from the NHS Modernisation Agency through Action on Urology to introduce CT for patients with suspected
renal colic in our Trust.
MATERIALS AND METHODS: Activity over a 12 month period after introduction of CT has been compared with 60 consecutive
patients undergoing IVU for suspected renal colic in 2002. Patients presenting between 09:00 and 17:00 underwent immediate CT.
Patients presenting outside these hours were admitted and investigated the following day. 423 patients underwent CT under this
protocol.
RESULTS: Stones were identified as the cause of pain in 223 (53%) and other significant pathology in 38 (9%). No abnormality was
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
days/patient in the IVU group.
CONCLUSION: Uncontasted CT is an accurate and economic investigation in acute renal colic. Our protocol has been adopted by
the Trust and will continue when Modernisation Agency funding ceases.
Emergency non traumatic urogenital imaging. What happens when CT is not available?
Demosthenes D Cokkinos, Elissavet Protopapa, Nikolaos Sakaridis, Ioanna Papaconstantinou, Styliani Giannou/Athens
Hippocration Hospital, Radiology Department
PURPOSE: Non contrast low dose CT is considered the standard imaging modality for non traumatic urogenital emergency
evaluation. When CT is not available, KUB films, ultrasound (US) and intravenous urography (IVU) are still being used. We assess
their efficacy in this clinical setting.
130

MATERIALS AND METHODS: 846 patients (453 male, 393 female, median age 44.6) were studied. 397 presented with acute renal
colic, 73 with scrotal pain, 130 with hematuria, 15 with pyelonephritis related symptoms, 168 with pelvic pain and 60 with urine
retention. They were examined with one or more imaging methods (KUB, US, IVU).
RESULTS: 750 patients underwent KUB, 846 US and 152 IVU. 509, 454 and 86 had negative KUB, US and IVU respectively.
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
urine retention cases due to prostatic hyperplasia. IVU confirmed pyelonephritis in 10. Altogether a diagnosis was made in 670/846
cases (79.2%). CT was needed in 28/846 (3.3%).
CONCLUSION:In most cases KUB, US and IVU were adequate for a definite diagnosis. Only in 3.3 % there was need for CT.
These modalities are still valuable for non traumatic urogenital emergencies evaluation.
SS17
Renal Injuries - Diagnostic Evaluation by Sonography
Dubravka Vidmar Institute of Radiology, University Medical Centre, 1525 Ljubljana, Slovenia
PURPOSE: Renal injury is present in 8-10% of all patients with blunt abdominal trauma. More severe renal injuries are
accompanied by macrohaematuria, but may also be associated with no haematuria at all. Sonography is the initial diagnostic
modality used in our institution to categorize injury in order to predict conservative or surgical treatment.
PATIENTS AND METHODS: Between March 2004 and March 2005 we diagnosed renal injuries in seven patients with blunt
abdominal trauma and one with penetrating wound (mean age 21.5 years). The mechanism was traffic accident in one, sport in
four, hit in two patients, gun shot in one. All patients had sonography in the Emergency Unit immediately after arrival. US
examinations were performed on Toshiba Power Vision 6000 with 3- 6 Mhz convex transducer with colour Doppler.
RESULTS: We diagnosed severe rupture in two patients, who were operated. The others had less severe injuries (superficial
lacerations with intraparenchimal and/or perirenal and subcapsular haematoma) and were treated conservatively. Sonography was
the only examination in six patients, while three had further examinations (two CT, one CT angiography, excretory urography),
which completely corresponded to US results.
CONCLUSION: An experienced examiner can describe renal injury sufficiently enough for decision about treatment. More invasive
diagnostic tools rarely give additional information.
SS18
SS19
CT imaging of iatrogenic urinary lesions after urologic, gynecologic, and obstetric procedures
Hrabak M, Stern-Padovan R, Smiljanic R, Perkov D, Lusic M.
Clinical Institute of Diagnostic and Interventional Radiology, Clinical Hospital Center Zagreb, University of Zagreb, School of
Medicine, Zagreb, Croatia
PURPOSE: Iatrogenic trauma is the leading cause of urinary lesions, which are usually clinically silent, and therefore associated
with delay in diagnosis and significant morbidity. The aim of the study was to evaluate the role of MSCT imaging in early detection
of iatrogenic urinary tract lesions.
MATERIALS AND METHODS: CT examinations performed using different protocols during 3-year period in patients with suspect
urinary tract lesion after urologic, gynecologic, or obstetric procedure, were retrospectively analyzed.
RESULTS: Urinary tract lesions were found after kidney transplantation and autotransplantation, nephrectomy, cystectomy,
prostatectomy, hysterectomy, caesarian section, ESWL, percutaneous nephrostomy, and penectomy. In most patients pathologic
fluid collections, including urinomas, hematomas, seromas, and abscesses, were evidenced. Multiple urogenital trauma, with urine
extralumination due to ureteral, urinary bladder and vaginal lesions, was found after caesarian section. Ureteral strictures were late
complications after renal procedures, hysterectomy or cystectomy. Vesicointestinal fistula was detected after transurethral
prostatectomy, and vesicovaginal fistula after hysterectomy with pelvic irradiation.
CONCLUSION: Iatrogenic urinary tract damage should be suspected if ultrasonography reveals free or localized fluid collection. CT
angiography and/or CT urography are primary modalities for assessment of suspect urinary tract lesions, because they enable fast
and accurate diagnosis before interventional or surgical treatment.
Retrospective analysis of ureteral distension as function of delay time after i.v. contrast-media injection followed by i.v.
saline infusion in CT-Urography
T Meindl, E Coppenrath, C Degenhardt, UL Müller-Lisse, M Reiser, UG Müller-Lisse, Institute for Clinical Radiology, University
Munich, Germany
PURPOSE: To evaluate the effect of delay time on distension of the upper urinary tract (UUT) in CT-urography (CTU).
MATERIAL AND METHODS: During a 7-months period, 54 patients (mean age, 60 years, mean serum creatine, 0,94mg/dL)
underwent multi-detector-CT of the UUT (4x2.5mm, 120kV, 30-50mAs/slice) after i.v. contrast media injection followed by infusion
of 250mL saline. UUT was divided into four segments, intrarenal-collecting system (IRCS), proximal, middle and distal ureter. Two
independent readers rated distension of UUT segments, score 1, no contrast filling, 2, distension less than 3mm or 3, distension
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.
Delay time groups were compared by means of Chi-square testing.
RESULTS: In total, 664 UUT segments were analysed. For the IRCS and proximal ureter significantly better distension was found
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
comparison to EU.
MATERIALS AND METHODS: 100 patients with urologic symptoms and non-dilated upper urinary tract. They were examined at
1.5T using T1 weighted,3D,fast spoiled gradient echo(FSPGR) after intravenous injection of 5-10mg. furosemide and, 30-60
second later,0.1mmol\KgmBW of Gd-DTPA. Coronal MIP and source images were compared to EU with regard to morphologic
accuracy, anatomic variability, filling defects and tumor visibility.
RESULTS: MRU was superior to EU in identification of renal fusion in crossed ectopic and horse-shoe kidneys and PCS
configuration in malrotated kidneys. For urolithasis MRU identify urinary stones in 75% of patients and EU in 91.7%. MRU was
superior in identification the exact location and nature of the renal and bladder masses. MRU revealed a distinct superiority in the
visualization of the renal parenchyma 156\200(78%) renal units. An equivalent information in 115\200(57.5%) of calyces,
120\200(60%) of pelves and 107\200(53.5%) of ureters
CONCLUSION: MRU provides an excellent anatomical information about non-dilated urinary tracts and parenchyma, without
repeated exposure to ionizing radiation and iodinated contrast media particularly in patients with congenital anomalies. Single plain
x-ray film should be included for better detection of urinary calcification. MRU if performed in conjunction with standard MRI
sequences avoids multiple separate diagnostic procedures.
SS21
Computed tomography angiography of haemodialysis arteriovenous fistulae: Impact of 3D image reconstructions in
complicated clinical cases
Dimopoulou A., Claesson K., Raland H., Wikström B and Magnusson A; Departments of Radiology, Transplantation Surgery and
Nephrology, Uppsala Academical Hospital, Uppsala, Sweden.
CONTENT: Haemodialysis arteriovenous fistulae (AVF) dysfunction remains one of the main complications in chronic
haemodialysis patients. The current method of choice for obtaining both accurate diagnosis and treatment is digital subtraction
angiography (DSA). An alternative, non-invasive, and accurate method has been developed in our department: computed
tomography angiography (CTA) with 3D image reconstruction. CTA is much more convenient for the patient and the radiologist, and
helps in the detail planning of further intervention therefore minimizing the number of times that patients must undergo invasive
procedures.
A series of complicated clinical cases of dysfunctional haemodialysis AVF are presented. Diagnosis was made by CTA with 3D
reconstructions and AVF stenosis was present in all cases. DSA with percutaneous transluminal angioplasty (PTA) was undertaken
and most probably would not have been successful, if the 3D images were not available, mapping out the exact pathways the
interventionist had to follow.
SS22
3T endorectal MR imaging in localizing and staging prostate cancer using gadolinium-enhanced FLASH3D subtraction
technique
Jurgen J. Futterer, Stijn W.T.P.J. Heijmink, Tom W.J. Scheenen, Christina A. Hulsbergen-van der Kaa, J. Alfred Witjes, Jelle O.
Barentsz
PURPOSE: To assess the localization and staging accuracy using a gadolinium-enhanced FLASH3D subtraction technique in
endorectal coil MR imaging of prostate cancer at 3T.
MATERIALS AND METHODS: Twenty patients with biopsy-proven and clinically localized prostate cancer underwent MR imaging
prior to radical prostatectomy. The T2-weighted MR images were acquired in three planes. Axial high spatial resolution T1-weighted
pre- and post-contrast enhanced FLASH3D sequences and subtractions were obtained.
All T2-weighted and subtraction images were prospectively evaluated and scored with regard to tumour localization and local extent
by two readers (4 years and 1 year of experience, respectively), using a 5 point scale by dichotomizing the readings with a cut-off
point of ≥ considered as T3-disease. Results were correlated with whole mount section histopathology.
RESULTS: Sensitivity and specificity for stage T3 disease were 94% and 98% for both readers using FLASH3D subtraction
images. With subtraction images 16 out of 20 index tumours were detected by the more experienced reader compared to 10 out 20
using T2-weighted images (p

1Radiology II, Radiology II, Innsbruck, Austria, 2Radiology, Radiology, Philadelphia, United States, 3Urology, Urology, Innsbruck,
Austria
PURPOSE: We performed a prospective randomized trial comparing less than or equal to 5 contrast-enhanced colour Doppler
ultrasound targeted biopsy cores to 10 grey-scale ultrasound guided systematic biopsy cores to determine the impact on the cancer
detection rate.
MATERIALS AND METHODS: We prospectively randomized 100 PSA screening volunteers with an elevated PSA (> 1.25 ng/mL
and free-to-total PSA < 18%) to undergo contrast-enhanced targeted or systematic biopsy. Contrast-enhanced targeted biopsies
with a limited number of cores (< 6) were performed of hypervascular areas of the peripheral zone during administration of the US
contrast agent SonoVue® (Bracco, Italy). A subjective grading of the vascularity from 0 to 3 was used: grade 0 = no colour signal, 1
= low density, 2 = medium density, and 3 high density of colour signals. The transit-time after bolus administration of the US
contrast-agent was assessed. Ten systematic biopsies were obtained in a standard spatial distribution. Cancer detection rates were
compared in the groups.
RESULTS: Cancer was detected in 16/50 subjects (32%) by targeted biopsy, and in 13/50 patients (26%) with systematic biopsy.
The cancer detection rate was significantly better for the targeted approach (p < 0.04). The detection rate for targeted biopsy cores
(15.6% or 39/250 cores) was significantly better than for systematic biopsy cores (6.8% or 34/500 cores, p < 0.001). Assessment of
the transit-time demonstrated an earlier and higher peak enhancement of cancer compared with benign tissue.
CONCLUSION: The overall cancer detection rate is significantly increased by contrast-enhanced colour Doppler targeted biopsy
compared with systematic biopsy.
SS25
Comparison of Contrast-enhanced Color Doppler Targeted Biopsy with Systematic Biopsy: Impact on Prostate Cancer
Detection in Men with PSA between 4 to 10
Leo Pallwein, Andrea Klauser, Ethan Halpern, Alexander Pelzer, Dieter Zur Nedden
PURPOSE: We performed a prospective study to compare contrast enhanced color Doppler ultrasound (US) targeted biopsy with
gray scale US guided systematic biopsy for prostate cancer detection in men with elevated prostate specific antigen (PSA) levels
between 4 to 10 ng/mL.
MATERIALS AND METHODS: We examined 380 male screening volunteers with a total PSA of 4.0 ng/mL to 10 ng/mL (free-tototal
PSA ratio < 18%). Two independent examiners evaluated each patient and a single investigator performed 5 or fewer contrast
enhanced color Doppler targeted biopsies into hypervascular regions in the peripheral zone. Subsequently another examiner
performed 10 systematic prostate biopsies. The cancer detection rates of the two techniques were compared. We further evaluated
the overall cancer detection rate.
RESULTS: The overall cancer detection rate with combination of the two methods was 37.6% (143 patients) with a mean PSA of
6.2 ng/mL. The cancer detection rate was 27.4% (104 patients) for contrast enhanced color Doppler targeted biopsies, and 27.6%
(105 patients) for systematic biopsy, and the detection rate of the combined methods lies above the 95% confidence interval limit of
both the enhanced color Doppler targeted biopsies and for the systematic biopsy. The detection rate for targeted biopsy cores (32.6
% or 233 of 715 cores) was significantly better than for systematic biopsy cores (17.9 % or 257 of 1430 cores, p = 1.25 ng/mL and free-to-total ratio of < 18%) were treated with
Dutasteride 14 days prior prostate biopsy. Contrast-enhanced color Doppler ultrasound (US) was performed before and 14 days
after Dutasteride treatment. Contrast-enhanced targeted biopsies (

All imaging was read independently by two radiologists with varying experience. Image quality characteristics and disease stage
probability were scored on a five-point scale. The prostate was divided into 14 sections for lesion allocation. Whole-mount section
histopathology was the standard of reference.
RESULTS: The anatomical details significantly improved (all p

PURPOSE: To analyse and to evaluate hysterosalpingography (HSG), performed without fluoroscopy, and laparoscopy as
diagnostic and therapeutic procedures in infertile women, and to determine the predictive value of HSG in the diagnosis of tubal
diseases compared to laparoscopy.
MATERIALS AND METHODS: We retrospectively analysed 362 women treated for infertility at the University Department of
Obstetrics and Gynecology in the period 2000-2001. Laparoscopy was done in all women, and HSG preceding laparoscopy in 185
women only. Results of tuboperitoneal factor of infertility achieved by both methods were compared, taking laparoscopy as the gold
standard.
RESULTS: In 46 of the 215 (21%) patients with primary infertility, and in 30 of the 147 (20%) women with secondary infertility,
laparoscopic findings were normal. Pathology was found in 79% of patients (myomas in 85 %, PCO in 19%, endometriosis in 27 %,
tuboovarian adhesions in 46%). HSG performed in 185 women revealed 0.68 sensitivity, 0.52 specificity, 0.55 positive and 0.64
negative predictive values for tubal factor of infertility.
CONCLUSIONS: In infertile patients laparoscopy proves to be the most appropriate diagnostic and therapeutic method. Statically
performed HSG, without fluoroscopy, preceding laparoscopy is a diagnostic method of limited value and is not recommended.
SS32
The role of transvaginal sonography in detection of congenital uterine malformations
Martina Ribic-Pucelj, Department of Obstetric and Gynecology, Ljubljana, Slovenia
PURPOSE: To find the prevalence of congenital uterine malformations (CUM) in women with preterm delivery (PD) and/or
intrauterine growth retardation (IUGR) and spontaneous abortions.
MATERIALS AND METHODS: We included in the study 124 women with spontaneous abortions, 107 with PD, 100 with PD and
IUGR, 101 with term delivery and IUGR and 200 women with normal pregnancy outcome. Transvaginal sonography (TVS) was
performed in the second half of the menstrual cycle with a 7-MHz vaginal probe Bruel and Kjaer.Diagnosis of CUM was based on
the shape of the uterine cavity, outer shape of the uterine fundus and anteroposterior/transversal ratio. The sensitivity of TVS was
98,5% and specificity 93,5% and was calculated in a previous study in which TVS findings were compared with those of
hysteroscopy and laparoscopy.
RESULTS: The prevalence of CUM in women with 1 spontaneous abortion was 24%, in those with 2 sp. abortions 42% and in
those with 3 sp. abortions 61%.The prevalence of CUM in women with PD was 35%, in those with PD and IUGR 32% and in those
with term delivery and IUGR 26%. CUM were found in 8,5% of women with normal pregnancy outcome. The prevalence of CUM in
general population was estimated to be 10.6%.
CONCLUSION: TVS is a highly sensitive, noninvasive and cost-effective screening test which enables early detection of CUM in
women with impaired pregnancy outcome and in those planning pregnancy. It enables also differential diagnosis and thus
appropriate surgical correction.
SS33
Effective EndoUro-Radiological Conferences: a model for success
M.C.Collins F.Salim L.Hawksworth J.Hall K.J.Hastie; Royal Hallamshire Hospital Sheffield S10 2JF U.K.
PURPOSE: To describe a model for effective organisation of local regular EndoUro-Radiological Conferences.
MATERIALS & METHODS: Conferences take place weekly.
Patients are referred for review from multiple sources including hospital wards and outpatients. All patients undergoing
EndoUrological procedures are also discussed. Clinicians referring patients for Conference review complete a referral form. A
Conference Coordinator compiles a data-sheet of patients and this includes reasons for review. Conference review takes place
using the data-sheet. Patients’ notes and Imaging are available in addition to electronic access to laboratory data. Following review,
an agreed outcome and action plan for each patient is entered onto the data-sheet by the Coordinator. This is circulated to all
concerned later by e mail.
RESULTS: This simple model of organisation brings a structure and method to the review of the many complex and demanding
cases that require resolution by EndoUrologists and Radiologists. It promotes focused discussion that leads to clear agreed
decision making. It also increases the number of patients that are reviewed.
CONCLUSION: An effective model for the organisation of EndoUro-Radiological Coferences leads to improved outcomes. The
employment of a Conference Coordinator is essential to this success.
SS34
Split renal function in patients with suspected renal artery stenosis – a comparison between gamma camera renography
and two methods of measurement with computed tomography
Henrik Björkman (1), Hampus Eklöf (1), Jonas Wadström (2), Lars-Göran Andersson (3), Rickard Nyman (1), Anders Magnusson
(1)
(1) Department of Oncology, Radiology and Clinical Immunology, Section of Radiology,
(2) Department of Surgical Sciences, Section of Transplantation, Uppsala University,
(3) Department of Nuclear Medicine, Akademiska Sjukhuset, Uppsala, Sweden
PURPOSE: To validate a method for calculating split renal function from computed tomography (CT) in comparison with gamma
camera renography, and to test a new method for the measurement, based on a volume rendering technique.
MATERIALS AND METHODS: Thirty-eight patients, aged 65.7 ± 11.6 (37.8 - 82.1) years, who had undergone both CT
angiography and gamma camera renography for a suspected renal artery stenosis were included. Split renal function was
calculated from the CT examinations by 2D measurements of area and mean attenuation in each of the image slices, and also from
automatic calculations of volume and mean attenuation in 3D reconstructions of the kidneys. Gamma camera renography with
99mTc-MAG3, with or without captopril enhancement was used as a reference.
RESULTS: A good correlation between the 2D CT method and renography was seen (r = 0.93). Mean difference was 4.7 ± 3.6 (0 -
12) percentage points per kidney. There was also an excellent correlation between the 2D and 3D CT methods (r = 1,00).
CONCLUSION: CT is equivalent with renography in determining split renal function, and the measurement from the CT examination
can be made faster and equally accurate with a 3D technique.
SS35
Measuring split renal function in renal donors: can computed tomography replace renography?
Henrik Björkman (1), Jonas Wadström (2), Lars-Göran Andersson (3), Hans Raland (1), Anders Magnusson (1),
135

(1) Department of Oncology, Radiology and Clinical Immunology, Section of Radiology,
(2) Department of Surgical Sciences, Section of Transplantation, Uppsala University,
(3) Department of Nuclear Medicine, Akademiska Sjukhuset, Uppsala, Sweden
PURPOSE: To develop and evaluate a method of calculating split renal function from computed tomography (CT) images based on
the assumption that the accumulation of contrast medium is proportional to the renal function, and to compare the results with
99mTc-MAG3 gamma camera renography.
MATERIALS AND METHODS: The study comprised a retrospective analysis of CT images and renograms from previous donors.
Twenty-seven potential renal donors were studied using a technique for measuring the area and mean attenuation of the separate
CT slices, thereby calculating the volume and total attenuation of the whole kidney.
RESULTS: The correlation between CT and renography was moderate (r = 0.43), but the range of results was narrow.
The ratio between the two kidneys was more even with CT (50 ± 2.1%) than with the renogram (48 ± 2.9%) (right kidney), and the
mean difference between the two methods was 3 ± 2.3 percentage points.
CONCLUSION: Calculations from the CT examination are equivalent to gamma camera renography in estimating split renal
function in potential renal donors.
SS36
MR imaging in diagnosis of post-renal transplant complications
T. EL-Diasty , M. Attia , A. Youssef , U. Galal , F. Tantawy .
Urology and Nephrology Center , Mansoura University & Benha Faculty of medicine , Zagazig University – Egypt .
OBJECTIVE: To evaluate the capability of magnetic resonance imaging ( MRI ) in diagnosis and differentiation of various post-renal
transplant complications .
PATIENTS AND METHODS: 181 kidney transplant recipients (139 males and 42 females) underwent duplex Doppler sonography
and MRI . Percutaneous nephrostomy (PCN) , antegrade pyelography and intra-arterial digital subtraction angiography ( IA-DSA )
were performed when indicated . A total of 245 MR examinations were carried out utilizing axial and sagittal T1 WIs, axial and
coronal T2 WIs , 3D Gd-enhanced FSPGR MRA , and MRU. The results of MRI were compared with those of histopathologic,
operative and / or invasive imaging findings.
RESULTS: There were 24 vascular, 12 urological, 22 fluid collections and 9 long term complications. Vascular complications
included graft artery (A) thrombosis (n=3), GA stenosis (n = 10), segmental infarction (n=6) , Pseudoaneurysm (n=3) and A-V
fistulae ( n=2 ). MRU was useful in 5 cases with ureteral obstruction, 4 cases with urinary leakage, 2 cases with PUJO and one
case with renal stone.
MRI detected 8 lymphoceles, 6 perinephric hematomas, 5 urinomas, and 3 perinephric abscesses. It could diagnose avascular
necrosis (AVN) of the hip in 7 patients and lymphoproliferative disease in 2 patients.
CONCLUSION: MRI is a reliable, non invasive diagnostic modality for assessment of kidney transplant recipients. MRI can
accurately diagnose both early and late post-operative complications.
SS37
Quantitative T1-perfusion and renal MRAngiography: a noninvasive all-in-one approach for renovascular evaluation
M. Dujardin1, S. Sourbron1, R. Luypaert1, P. Van , Schuerbeek1, S. Makkat1, F. Deridder1, P. Van der Niepen2, D. Verbeelen2,
T. Stadnik1; 1Radiology/Befy, Vrije Universiteit Brussel, Brussels, Belgium; 2Nefrology, Vrije Universiteit Brussel, Brussels, Belgium
PURPOSE: MRI has the potential to provide anatomical and functional information. We investigated the feasibility of implementing
T1-quantitative renal perfusion in the routine renal artery MRA-protocol.
MATERIALS AND METHODS: Single slice Turboflash (TR4.4,TE2.2,TI 180,FA50°, matrix128/256,NA 400) was first applied during
the injection of 0.05mmol/kg Gd-DTPA at 2ml/sec. Conventional 3DCE-MRA was then performed with another 0.1 mmol Gd-
DTPA/kg. Perfusion post-processing included conversion to tracer concentrations and deconvolution with an aorta AIF. Parametric
maps of renal blood flow(RBF), renal volume of distribution(RVD) and mean transit time(MTT) were calculated. Single kidney
perfusion values were compared to literature values.
RESULTS: Perfusion maps with sufficient contrast to noise for cortical ROI delineation were obtained in all patients. MRA revealed
one congenital single kidney, but no renal artery stenosis. Average RBF, RVD and MTT were 1.3 ml/min/ml (SD 0.2ml/min/ml) , 0.5
ml/ml (SD0.1 ml/ml) and 24s (SD5s). Mean cortex/medulla ratio was 3 (SD0.4), which is near to the literature value. RBF values are
lower than those found in the literature, mainly due to inflow effects in the AIF. MRA quality was not at all compromised: contrast
filling of pyelum and proximal ureter provided additional excretory information.
CONCLUSION: The combination quantitative T1-perfusion/MRA has a potential for noninvasive all-in-one renovascular evaluation.
SS38
Changes in renal blood flow related to extracorporeal shock wave lithotripsy measured by FLASHSTAR
Eva Pallwein, Leo Pallwein, Christian Kremser, Werner Judmaier, Günther Janetschek, Ferdinand Frauscher, and Michael
Schocke; Radiology I and II. Innsbruck, Austria.
PURPOSE: FLASHSTAR is a method for measuring tissue perfusion without using a contrast agent. Our purpose was to assess
renal blood flow (RBF) changes before and after extracorporeal shock wave lithotripsy (ESWL).
MATERIALS AND METHODS: We examined 13 patients (mean: 49±13 years) 12 hours before and 12 hours after ESWL using
a 1.5 Tesla MR Scanner. In each patient the treated and untreated kidneys were separately covered by 9 slices. RBF maps were
created by subtraction of two datasets acquired alternately with and without 180° inversion applied to spins in the proximal renal
arteries. Changes of RBF were calculated based on Histogram analysis of the subtraction maps.
RESULTS: All patients showed a significant (t-test, p< 0.05) change of RBF maps, which means a decreased tissue perfusion in
the treated as well as in the untreated kidneys. The RBF maps correlated well (p> 0.7, Pearson) after ESWL.
CONCLUSION: A significant decrease in RBF maps after ESWL in all patients could be expected in the treated kidneys, which is in
line with current literature. The significant decrease of RBF in the untreated kidneys indicates a systemic perfusion effect of ESWL.
FLASHSTAR appears to be a sensitive tool for the determination of RBF and its relative changes.
136

POSTER SESSION
P1
Low field open MRI of the adrenal glands: a pictorial essay
Robert Berkenblit, Montefiore Medical Center, Bronx, NY USA
PURPOSE: MRI is an established tool for evaluating adrenal lesions. Open MRI systems have become fairly popular over the last
fifteen years or so representing 26% of MRI systems in the U.S.A. in 2003. There are limitations to open low field MRI systems,
mainly related to speed and coverage. However, by utilizing appropriate protocols for a low field system, quality diagnostic studies
of the adrenal glands can be performed. This poster demonstrates a number of adrenal lesions imaged on a 0.3 T open MRI.
MATERIALS AND METHODS: The patients in this poster could not tolerate a closed bore MRI. Spin echo T1 and fast spin echo T2
weighted imaging and gradient echo in and out of phase imaging were employed. Fat suppression, if needed was achieved with
STIR. Post contrast imaging, when necessary was performed in dynamic and delayed fashion.
RESULTS: Utilizing protocols appropriate to low field MRI scanners a number of adrenal lesions imaged at 0.3 T are presented
including adrenal cysts, adenomas, metastatic disease and pheochromocytoma.
CONCLUSION: Open low field MRI is a viable option for adrenal MRI in patients that otherwise could not tolerate a closed MRI.
P2 Multicystic dysplastic kidney – an audit of 15 years of experience in Plymouth, UK, 1990-2004
Narayanaswamy S, Jones R/ Derriford Hospital, Plymouth
PURPOSE: To report our experience of multicystic dysplastic kidney (MCDK) in children, assessing the outcome of imaging studies
and its management.
MATERIALS AND METHODS: 33 patients with a diagnosis of multicystic dysplastic kidney were identified in a 15-year period
between 1990- 2004 at Plymouth. The data was obtained to assess the outcome of imaging studies, complications and
management of this common cystic disease of the kidney.
RESULTS: Out of 33 cases of MCDK, seven (21%) were bilateral and were associated with both non-renal and renal anomalies. Of
the remaining 26 cases of unilateral MCDK twenty-five were identified by prenatal ultrasound. DMSA scan confirmed total absence
of function on the affected side in all cases of unilateral MCDK. VCUG performed in 20 children showed vesico-ureteral reflux in 4
cases (15%). Two infants of unilateral MCDK had hypertension and one was associated with Alagille syndrome. Most of the cases
were managed conservatively but surgical intervention was needed only in 3(11%) cases.
CONCLUSION: Prenatal ultrasonography is a valuable tool in the diagnosis of most of the cases of MCDK. Routine use of VCUG is
questionable as there were only few cases of VUR in our series which supports the results from most of the other studies. DMSA
scan confirmed non-function in all cases of MCDK on the affected side. This study demonstrated low risk of associated
complications and also confirmed that surgical intervention is not always necessary for an uncomplicated unilateral MCDK
P 3
Fat is the key
R. García Figueiras(1), C. Villalba Martín(1), A. García Figueiras(2), M. Otero Echart(1), G. Pazos(1), Laura Oleaga (3), Inés
Requejo(2) (1)Department of Radiology Complexo Hospitalario de Santiago de Compostela (Spain) (2)Departement of Radiology
Complexo Hospitalario Juan Canalejo
PURPOSE: The differential diagnosis of many abdomino-pelvic pathological processes is wide. Demonstration of microscopic or
macroscopic fat within a lesion or detecting involvement of the fatty tissue at non-invasive imaging are important key point for the
differential diagnosis and for the detection of pathologic entities.
MATERIAL AND METHODS: A retrospective analysis of patients diagnosed based on fatty involvement or presence of fat within
the lesion was performed. Data on CT, MR and US were collected. Identification of macroscopic fat with CT is based on the
attenuation (typically less than –20 HU). Several MR imaging techniques have been developed for fat identification: spectroscopic
fat saturation and chemical shift (in-phase/opposed-phase) imaging. Urogenital and non-urogenital fat-containing entities or
involving fatty tissue are included. Differential diagnosis is made. Presentation includes myelolipomas, angiomyolipomas,
teratomas, adrenal adenomas, liposarcomas, lipomas, retroperitoneal fibrosis, and acute abdominal processes with fat involvement
(renal colic with perirenal fat- stranding, epiploic appendagitis, omental infarction, appendicitis).
RESULTS: We illustrate all the spectrum of imaging findings of fatty lesions and fat involvement in abdomino-pelvic pathological
processes.
CONCLUSIONS: Demonstration of microscopic or macroscopic fat within a lesion or fatty tissue involvement can help improve the
diagnostic accuracy for abdomino-pelvic lesions and can be a key point in formulating an appropriate diagnosis based on imaging
findings.
P4
Massive pleural effusion as the first manifestation of renal cell carcinoma-a case report
Mojca Juvan-Žavbi University Clinic of Respiratory and Allergic Diseases Golnik, Slovenia E-mail: mojca.juvan@klinika-golnik.si
INTRODUCTION: Renal cancer accounts for 2-3% of all adult cancers occurring predomonantly in the sixth to eighth decade of life
and being nearly twice as frequent in men as women. Approximately, one third of the patients present with metastatic disease at
the time of diagnosis. Although renal cell carcinoma (RCC) can practically metastasise to any part of the body, the majority of
metastatic lesions are located in the lung (50%) and bones(49%). In several large series analyzing all malignant effusion, RCC has
been the cause of 1-2,2% of malignant pleural effusions (Cancer 1998). Clinically obvious pleural metastases from RCC are
considered as exceptionally rare. They are mainly presented as malignant pleural effusions, they coexist with lung metastases and
never occur without involvement of other metastatic site. The prognosis of pleural metastases in RCC is generally poor and the
majority patients die within six months from the diagnosis.
CASE REPORT: A 61-year-old man with a 9-month history of dyspnoea, decreasing exercise tolerance and chest pain was
admitted for investigation of a right pleural effusion and a lesion in the left lung . He did not refer urinary symptoms and routine
137

laboratory evaluation of serum and urine was unremarkable. Chest X-ray revealed massive right pleural effusion and some contra
lateral mediastinal shift. It showed also left sided 1cm large pulmonary lesions. Pleural fluid was haemorrhagic and negative for
malignancy. Bronchoscopy didn’t reveal any endobronchial patology. Abdominal ultrasonography revealed an irregular 6,4 x 5,6 cm
large mass arising from the lower pole of the left kidney, right sided massive pleural effusion and 3,2 x 1,5 cm large diaphragmatic
pleural nodule. Computed tomography of the chest and abdomen confirmed an irregular 6,7x5,6 cm large mass arising from the
lower pole of the left kidney and right sided massive pleural effusion. CT revealed irregular nodules of the right parietal pleura, left
sided pulmonary nodules and a 2 x 3cm large left adrenal mass. Ultrasound- guided fine needle aspiration biopsy of the renal mass
proved RCC of the left kidney. The diagnosis was primary renal cell carcinoma with metastases to lung, pleura and left adrenal
gland.
CONCLUSION: Complete evaluation led to the diagnosis of pleural metastases and malignant pleural effusion secondary to
metastatic RCC. Pleural effusion in RCC is a rare presenting feature especially as the first manifestation of the disease. The
present case indicates that: RCC should be suspected and considered in differential diagnosis of massive pleural effusion and / or
pleural mass found in a male patient elder than 60 year-old.
P5
MR urography of obstructive uropathy: diagnostic value of the method in selected clinical groups
Joanna Zielonko Institute of Radiology and Nuclear Medicine, Medical University of Gdansk, St. Debinki 7, 80-211 Gdansk, Poland
PURPOSE: To evaluate the role of MRU in the diagnosis of obstructive uropathy in selected clinical groups.
MATERIALS AND METHODS: Sixty patients with obstructive uropathy underwent static fluid MRU (sMRU), conventional MR
sequences, excretory MRU (12 cases). The degree of the urinary tract dilatation, the level and type of obstruction were estimated.
Four groups of pathologies were distinguished: calculi, strictures of ureteropelvic junction (UPJ), benign and malignancy-induced
ureterostenosis. Results were compared with IVU, CT, US, clinical and histopathological data.
RESULTS: In patients with urolithiasis sMRU correctly depicted the degree of ureterohydronephrosis in 85%, in cases of UPJ
stenosis and malignancy-induced ureterostenosis in 100% and in the group of benign ureterostenosis in 91%. Determination of
obstruction level was adequate in 92% of stones and in 100 % of non-calculous ureteral strictures. Completed with conventional
MR sequences sMRU depicted tumour or infiltration in 83% cases of malignancy-induced ureterostenosis. In the remaining groups
neoplasm was excluded in 91%. Filling defects were verified with IVU/CT to exclude tumours.
CONCLUSION: MRU is useful technique in assessment of obstructive uropathy, especially that of non-calculous origin. Among
different clinical applications MRU is superior in the evaluation of dilated urinary tract in altered anatomical conditions (e.g. ileal
neobladder).
P6
Multi-detector row CT in the evaluation of renal masses
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, Th. Vadivoulis1, D. Baltogiannis2, N. Sofikitis2, S. C. Efremidis1. 1Department of
Clinical Radiology 2Department of Urology University Hospital of Ioannina, GREECE.
Renal cell carcinoma is the most common malignancy of the kidney and accounts for 2% of all visceral neoplasms. The goals in
imaging renal masses include the reliable differentiation between benign and malignant lesions and also the accurate delineation of
the extent of the disease to ensure optimal treatment planning. With the introduction of multidetector CT, especially 16- row CT
scanners the radiologic evaluation of the urinary tract is changing rapidly. A 16-row CT scanner has the advantages of shorter scan
duration, of 0.5 seconds on the average, practically eliminating motion artifacts and of thinner collimation, section thickness of 0.8
mm are routinely employed, allowing the detection of very small lesions. Moreover the near-isotropic voxels provide the creation of
high-resolution multiplanar and three- dimensional (3D) reformatted images, with excellent anatomic details. Sixteen-slice
technology is expected to improve the preoperative evaluation of patients with renal tumors. The objectives of this presentation are:
(a) to illustrate the CT protocol for evaluating patients with renal masses, (b) to present CT findings for the differentiation between
benign and malignant renal tumors, (c) to recognize the CT findings for staging renal cell carcinoma.
P7
Sonographic detection of renal and ureteral calculi - diagnostic accuracy of the twinkle sign
Pallwein L.1, Frauscher F.1, Andrea K.1, Gradl H.1, Schurich M.1, Struve P.1, Peschel R.1, Bartsch G.2 1 Department of Radiology
II 2 Department of Urology Medical University Innsbruck
PURPOSE: To compare the detection of urinary stones using gray- scale ultrasound (US) to the accuracy of diagnosis using the
color Doppler (CD) twinkle sign.
MATERIALS AND METHODS: 41 patients with at least one urinary stone on unenhanced CT were evaluated with US and CD. The
likelihood of a stone was rated sonographically at 8 locations within each kidney/ureter - intrarenal upper-pole, intrarenal mid- pole,
intrarenal lower-pole, renal pelvis, uretero-pelvic junction (UPJ), mid ureter, distal ureter and uretero- vesicle junction (UVJ). Each
location was rated on a 5 point scale (1- definitely negative; 5- definitely positive). Comparison of US and CD diagnosis was
performed with a clustered receiver operating characteristic (ROC) analysis.
RESULTS: 77 stones were present in 41 subjects, including intrarenal (n=47), renal pelvis (n=5), UPJ (n=8), ureter (n=5) and UVJ
(n=12) stones. Based upon US, the diagnosis of stone was made with confidence in 66% (51/77) and with CD twinkle in 97%
(75/77). Ten false positive stones were suggested within an intrarenal location in 10 subjects, while 1 false positive stone was
suggested at a UPJ. One of the false positive intrarenal stones was suggested only by the Doppler twinkle sign. Clustered ROC
analysis demonstrated that the Doppler twinkle sign (Az = 0.99) was significantly better than conventional gray scale criteria (Az =
0.95) for the diagnosis of urinary stones (p = 0.005).
CONCLUSION: The CD twinkle sign improves the detection and confidence of diagnosis for urinary calculi with minimal loss of
specificity. Overall diagnostic accuracy is significantly improved by the addition of CD.
P8
Contrast enhanced ultrasound in the evaluation of renal trauma
G.Regine, M. Atzori, V. Buffa, M. Galluzzo, V. Miele, L. Adami. Department of Radiology, S. CAMILLO Hospital, Rome, Italy
PURPOSE: To evaluate diagnostic impact of contrast enhanced ultrasound respect of baseline ultrasound and Multidetector-Row
CT in patient with renal trauma.
138

MATERIALS AND METHODS:Between March 2004 and February 2005, 277 patients, with abdominal blunt trauma, were
evaluated. 28/277 showed renal lesions, the severity of renal injury was graded by the American Association for the Surgery of
Trauma Organ Injury Severity Scale. All patients with hematuria (63) were evaluated with baseline ultrasound, after II generation
(Sonovue) ultrasound contrast agent injection and multiphasic MDCT scan.
RESULTS: 5/28 traumatic parenchimal lesions with perirenal fluid collection were identified at ultrasound baseline. 28/28 renal
parenchimal lesions, with or without perirenal or retroperitoneal hematoma, were identified at contrast enhanced ultrasound. The
MDCT multiphase corfirmed all positive cases at contrast enhanced ultrasound, and moreover rated the lesions’ grade, particulary
the IV and V using 3D reconstruction. The urinary excretory system lesion was identified at delay phase.
CONCLUSION:Our experience confirmed the diagnostic accuracy of integrated imaging both for correct diagnosis and for correct
patient management. Specifically we have noted the possibility of staging low grade lesion and performing follow-up examination of
renal lesions using contrast enhanced ultrasound which also reduces exposure to radiation (less MDCT examinations).
P9
Spiral CT evaluation of nontraumatic haemorrhage of adrenals` adenoma
Patelis E., Tavernaraki K, Constantinidis F., Alexiou K., Panagiotakopoulou A, Antonopoulos P. Computerised Tomography
Department, 1st I.K.A. Hospital-Simanoglion Hospital, Athens, Greece
Nontraumatic adrenal haemorrhage is a rare pathology that can be diagnosed by computed tomography, and may be associated
with a variety of conditions. The causes of such haemorrhage can be classified into five categories: (a) stress, (b) hemorrhagic
diathesis or coagulopathy, (c) neonatal stress, (d) underlying adrenal tumors, and (e) idiopathic disease. Most articles on
nontraumatic adrenal hemorrhage consist of a single case .Acute hemorrhage may be present in and around the mass and
accompanied by severe hypertension crisis and abdominal pain However, unlike in primary carcinoma, foci of hemorrhage and
necrosis are rare in adenoma, probably due to its hypovascular nature. Although a cortical adenoma is the most common neoplasm
of the adrenal gland, massive hemorrhage from an adenoma is extremely rare (54–57). Herein we report 3 cases of non traumatic
hemorrage from adrenal adenomas. 3 patients, with a history of severe hypertension crisis, was admitted at the outpatients
department with abdominal pain. A spiral CT examination was performed using axial slices of 3 mm thickness, before and after the
iv administration of contrast material.
RESULTS: 1An oval lesion of low density (-22HU ) with sharp and well-defined margins, with hyperdense foci due to hemorrhage
,was observed in the right adrenal gland . 2.A round ,homogeneous mass with hypodense CT attenuation values (-10HU) was
found in the right adrenal gland ,with area of high density (61HU) in it .3. An oval low density lesion measured 2 cm, was observed
in the left adrenal gland. A hyperdensity foci was found in the medial aspect of the lesion.
CONCLUSION: Spiral CT is a reliable method in the investigation and diagnosis of non traumatic adrenal adenoma hemorrhage.
P10
Retained calculi and complications of extracorporeal shock wave lithotripsy: evaluation with helical computed
tomography
Patelis E., Tavernaraki K., Kedri K., Georgoulis P., Petroulakis A., Antonopoulos P. Computerised Tomography Department, 1st
I.K.A. Hospital-Sismanoglion Hospital, Athens, Greece
PURPOSE: We report our experience with non-enchanced computerized tomography (CT) after extracorporeal shock wave
lithotripsy (ESWL) in patients considered to be at high risk for retained calculi and other complications.
MATERIAL AND METHODS: A retrospective review was performed on 125 consecutive patients who had been treated with ESWL
between May 1997 and June 2000.Lithotripsy treatments were outpatient procedures without anaesthesia. CT was obtained in 125
patients with 12 to 36 hours of lithotripsy for staghorn or large non staghorn renal calculi. Cases were grouped according to the CT
findingw as no retained calculi, insignificant retained calculi (fragments 1 to 3mm.),retained calculi and hematomas.
RESULTS: No calculi were seen in 70 patients (56%) and retained calculi were identified in 45 (36%). Insignificant calculi were
noted in the remaining 10 patients. Four renal and three periureteral hematomas were diagnosed. In these patients, who presented
with severe low back pain immediately after they were treated with ESWL ,retained calculi were identified.
CONCLUSIONS: Non-enhanced helical computed tomography is an adequate diagnostic tool for the assessment of the clinical
outcome and possible complications of ESWL. Non-enhanced helical computed tomography is the best method to determine if a
patient is stone –free after EWSL, aids in locating retained calculi or rare complications, such as renal and periureteral hematomas.
Further therapeutic management of these patients may therefore, adequately be designed.
P11
Spontaneous rupture of renal cell carcinoma
N. Pertia, N. Khutulashvili, M. Phachuashvili Radiological diagnostic and telemedicine center, Tbilisi, Georgia
PURPOSE: Renal cell carcinoma consisted of more than 80 % of all renal tumors. Due to widespread use of modern radiological
modalities up to 35 % of renal tumors are detected incidentally. However some tumors should be detected by extremely unusual
way. Spontaneous renal haematoma of renal tumor is an uncommon event and diagnostic challenge for the radiologist as well as
for urologists. We presented one case of spontaneous rupture of renal cell carcinoma.
MATERIALS AND METHODS: A 67-year old man was admitted at the radiological department from the emergency room. Patient
had a severe flank pain and unstable blood pressure. He had a no previous history of hematuria. Ultrasound showed a large
heterogeneous mass in the right retroperitoneal space. Patient underwent CT examination with contrast enhancement. RESULTS:
CT examination with contrast enhancement showed retroperitoneal haematoma around the right kidney, and a large
heterogeneous mass in the kidney with a contrast material inclusion. We suspected presence of renal cell carcinoma. Patient was
operated in urological department, nephrectomy through transperitoneal approach was done. Histological evaluation confirmed
diagnosis of renal cell carcinoma (clear cell variant grade 3).
CONCLUSION: In case of admission of patient with large heterogeneous mass in retroperitoneal space probability of spontaneous
rupture of renal tumor should not be excluded. In such cases immediate operative treatment is indicated.
P12
Colic pain in patients with hyperechoic US appearance of renal medulla
J. Manavis, S. Deftereos.
PURPOSE: We present conditions which may be associated with hyperechoic medulla of the kidney, stone formation and colics.
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MATERIAL AND RESULTS: In the last ten years, hyperechoic appearance of renal medulla was demonstrated by ultrasound in 16
consecutive patients.
RESULTS: The final diagnosis was gout in six patients, medullary sponge kidney in two, Sjogren's syndrome in two, Lesch-Nyhan
syndrome in one, hyperparathyroidism with adenoma of the parathyroid glands in two patients, Wilson's disease in two cases and
primary hyperaldosteronism in one patient. Two patients had renal stones at the first exam and five revealed nephrolithiasis during
the follow up period. Five patients had frequent and/or recurrent colic pain.
CONCLUSION: Renal colics can present in patients with hyperechoic medulla in 48% and we suggest that ultrasonography is the
method of choice not only in the diagnosis but also and especially in the follow up of these patients.
P13
Bilateral tuberculosis infection of adrenal glands: utility of CT-guided biopsy in diagnosis
CP Kalogeropoulou (1), EN Liatsikos (2), ZG Papathanassiou (1), I Tsota (1),T Petsas (1)
(1): Department of Radiology, University Hospital of Patras, Greece
(2): Department of Urology, University Hospital of Patras, Greece, T Petsas
PURPOSE: Despite the progress made in therapy and prophylaxis during the past two decades, tuberculosis still remains a crucial
worldwide clinical problem. Solitary adrenal tuberculosis combined with adrenal insufficiency consist a rare and usually irreversible
pathological entity. An uncommon case of primary adrenal tuberculosis, diagnosed by means of CT-guided biopsy, is described.
MATERIALS AND METHODS: A young adult presented with lumbar pain, fever, and fatigue. Abdominal imaging demonstrated
bilateral adrenal enlargement. Laboratory investigations indicated adrenal insufficiency. Mantoux reaction was positive but there
was no evidence of lung or urinary infection. CT-guided fine needle aspiration of the left adrenal gland was performed, utilizing a
dorsal, paraspinal approach and tissue specimens were obtained through a 20G needle. Histology established the diagnosis of
tuberculosis.
RESULTS: The patient received adequate medication. One month later his condition was considerably improved; his fever ceased
and he started to gain weight but he will continue to be under laboratory and imaging follow-up, every two months.
DISCUSSION: Patients with adrenal masses should be evaluated for tuberculosis, even though no evidence or history of primary
source is established. Percutaneous biopsy of adrenal masses is proved to be a valuable diagnostic tool in the differential diagnosis
of adrenal masses, especially when nondiagnostic imaging findings are depicted.
P14
The role of spiral CT in the investigation and diagnosis of pyelonephritis
Patelis E., Dalamarinis K., Constantinidis F., Tavernaraki K., Constantinidou E., Antonopoulos P.
Department of Computerised Tomography, 1st I.K.A. Hospital-Sismanoglion General Hospital, Athens, Greece
PURPOSE: The purpose of this study is the evaluation of the reliability of spiral CT examination in patients with clinical symptoms
indicating possible pyelonephritis.
MATERIALS AND METHODS: During a five-year period, 46 patients with a possible clinical diagnosis of pyelonephritis were
examined. The spiral CT examination was performed using a PICKER PQ 5000 machine, before and after intravenous contrast
material infusion, with 5mm thickness axial slices. After the imaging results' study, the diagnosis was reached based on the CT and
clinical findings and the laboratory examinations (blood tests, biochemical analysis, urine cultures).
RESULTS: The CT findings in 23 of the patients were those of small (>1cm), hypodense lesions in the renal cortex, resembling
renal microabscesses. In 5 patients a single, hypodense lesion, with density similar to that of water, resembling a single abscess,
was observed. 14 patients were reported to have unilateral kidney enlargement. The findings in 11 patients were consistent with
those of small, hypodense lesions with small air bubbles. In 4 of these patients multiple stones in the pelvicalyceal system of the
affected kidney were also found.
A scant nephrogram of the involved kidney with small hypodense areas, consistent with thrombosed renal artery branches was
observed in 7 patients. A constant CT finding was the abnormal appearance of the renal fascia, which in 28 cases was
accompanied by a localised exudative reaction. One patient was reported to have an abscess of the psoas muscle.
CONCLUSION: Spiral CT is a reliable examination for the diagnosis of pyelonephritis and the determination of the degree of renal
damage.
P15
Acute pyelonephritis: comparison of diagnosis with CT and contrast-enhanced US
Andrea Klauser, Leo Pallwein, Andreas Berger, Ammar Mallouhi, Dieter Zur Nedden
PURPOSE: To assess the ability of contrast-enhanced ultrasound (US) in the detection of renal parenchymal changes in acute
pyelonephritis.
MATERIALS AND METHODS: Fifty patients (mean age: 30.2 years; range, 14 – 67) with symptoms suggesting acute
pyelonephritis were investigated. The renal US studies were performed using an Acuson Sequoia unit (Acuson, MountainView,
Cal.) with Cadence contrast pulse sequencing technology (CPS). The US contrast agent SonoVue® (Bracco, Italy) was
administered intravenously to a maximum dose of 4.8 mL. The computed tomography (CT) studies, which served as the "gold
standard", were performed with a multi detector row unit (Sensation 16, Siemens, Erlangen, Germany) within 12 hours after the US
studies. Triangular areas of decreased perfusion visible on both longitudinal and axial scans were considered indicative of acute
pyelonephritis on contrast US. On CT, areas of decreased attenuation of the renal parenchyma visible immediately after injection of
iodinated contrast agent or areas of increased attenuation on delayed scans were considered indicative of acute pyelonephritis.
The US and CT examinations were performed by two different investigators. We compared the contrast US findings with the
findings obtained by CT.
RESULTS: For 41 (98%) of the 42 patients with CT-proven acute pyelonephritis, contrast-enhanced US correctly diagnosed this
condition. The one patient in whom acute pyelonephritis was not revealed by contrast-enhanced US was an obese 17-year-old girl.
Furthermore this girl was one of the first patients to be included in the study. No false positive findings were obtained by contrastenhanced
US.
CONCLUSION: Contrast-enhanced US and CT appear to be equally sensitive for the detection of acute pyelonephritis. Therefore
contrast-enhanced US seems to be able to replace CT.
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P16
Evaluation of cystic renal masses: comparison of CT and contrast enhanced US by using the Bosniak classification
system
Michele Bertolotto, Libero Barozzi, Stefania Gava, Loretta Calderan, Anna Tiberio, Maria Assunta Cova/Dept Radiology and
Urology, University of Trieste; Ospedale S.Orsola-Malpighi, University of Bologna
PURPOSE: To compare contrast enhanced ultrasound (CEUS) and CT in evaluation of atypical cystic renal masses by using the
Bosniak classification system.
MATERIALS AND METHODS: Images of 33 consecutive patients with 35 atypical cystic renal masses who had undergone both
CEUS and CT were retrospectively analyzed by two radiologists in consensus. For each lesion, images were compared for
thickness of wall and septa, number of septa, presence of calcifications, and contrast enhancement. Each lesion was categorized
using the Bosniak classification system on CEUS images first, and then on CT images.
RESULTS: On CEUS there were 12 category II, 9 category IIF, 8 category III, and 6 category IV lesions. Findings on CT images
were similar in 26 (74%) lesions; in 9 (26%) lesions CEUS depicted more septa, or increased wall and/or septa thickness in
comparison with CT resulting in an upgrade of the classification from category I to category II and IIF in 2 and 4 lesions,
respectively, and from category II to category IIF in 3 lesions.
CONCLUSION: In comparison with CT CEUS provides better evaluation of subtle thickening of the wall and/or septa of atypical
cystic masses, and increased contrast resolution between liquid and nonenhancing septa which can result in upgraded Bosniak
classification.
YP17
Large adrenocortical oncocytoma: case report
Nasr El-Tabey, M.Sc.*, Essam Abou-Bieh, M.Sc.**, Ahmed Farouk, MD**,And Ibrahim Eraky, MD *,
* Urology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
** Radiology Department, Urology and Nephrology Center, Mansoura University, Mansoura, Egypt.
CONTENT: We report a case of adrenocortical oncocytoma. The term oncocytoma is used to describe a tumor of cells with
granular esinophilic cytoplasm packed with mitochondria and arranged in alveolar, tubular solid pattern. The mass almost always
non functioning and usually discovered incidentally.
Adrenocortical oncocytoma should be considered in the differential diagnosis of benign non functioning adrenal masses. And the
diagnosis depend on the characteristic MRI picture.
P18
CT-urography (CTU) added on to CT of the abdomen: retrospective comparison of standard-dose and low-dose CTU
protocols
T Meindl, E Coppenrath, UL Mueller-Lisse, C Degenhart, MF Reiser, UG Mueller-Lisse, Institute for Clinical Radiology, university
Munich, Germany
PURPOSE: Comparison of routine and low-dose CTU protocols regarding diagnosis of pathologies of the upper urinary tract (UUT).
MATERIAL AND METHODS: During a 1.5-year period, 92 patients with diseases suspected to affect the UUT underwent contrastenhanced
CT of the abdomen, including a portovenous/nephrographic and a delayed excretory phase. CTU was obtained with
4x2.5mm collimation after administration of i.v. saline. In group 1, CTU was performed with a standard (n=42, 120kV, average
175.6 mAs/slice), in group 2 with a low dose examination protocol (n=50, 120kV, 29mAs/slice). Pathologies of the UUTs were
corroborated by combination of portovenous/nephrographic scans and all available clinical informations (clinical exam, ultrasound,
excretory urography, surgery). CTU scans were reviewed by two independent readers (R1, R2) blinded to corroborating data.
UUT pathology (ureteral dilatation, compression, intraluminal lesions) was diagnosed using a 5-point confidence scale: pathology
definitely absent (1), probably absent (2), undecided (3), probably present (4), definitely present (5). Statistics were done by ROCanalysis
and Chi-Square testing.
RESULTS: Sensitivity and specifity for ureteral dilatation was equally good in routine and low-dose CTU (group 1, sensitivity 92.9%,
specifity 99.7%; group 2, sensitivity 96.2%, specifity 99.4%; sensitivity, c2=0.01, p=0.92; specifity, c2=0.062, p=0.8). For ureteral
compression, no significant differences between the groups were found (group 1, sensitivity 96.4%, specifity 98.8%; group 2
sensitivity 90.9%, specifity 99.0%; sensitivity, c2=0.013, p=0.91; specifity, c2=0.23, p=0.6). Number of intraluminal lesions was low,
in group 1 5/5, in group 2 1/1 (R1) and 0/1 (R2) lesions were detected.
CONCLUSION: Dose-reduced CTU suffices to determine UUT dilatation and compression. However, it is unlikely to depict
intraluminal lesions reliably.
P19
Incidentally discovered urinary and nonurinary lesions by multidetector noncontrast CT for flank pain
Huda Refaie *, Ahmed Shokier. **
*Radiology department; **Urology department. Urology & Nephrology center Mansoura university, Mansoura-Egypt
PURPOSE: Our center increasingly using multidetector unenhanced CT ( MD NCCT ) for evaluation of flank pain. The aim of our
study was to determine the cause of flank pain wheather urinary stones or incidentally discoverd other causes.
MATERIALS AND METHODS: A total of 1500 patients with flank pain with or without haematuria for whom MD NCCT was done
were the subject of this study. MD NCCT was accompanied by a scout film which looks to be a small KUB.
RESULTS: Our patients were classified according to the cause of flank pain to four Groups:
-55% of patient with urinary calculi whom diagnosed either by primary or secondary signs of obstruction.
-16% of patients with noncalculus urinary causes e.g. acute pyelonephritis, haemorrhagic angiomyolipoma , haemorrhagic cysts in
polycystic kidney disease , renal abscess and vesical mass .
-In 11% of patients, the cause of flank pain was non urinary in origin e.g.pelvic mass, retroperitoneal lymphadenopathy ,
cholecystitis and pancreatitis .
-In 18% of patients there were incidentally discovered lesions which could not explain flank pain e.g. small suprarenal mass ,
hepatic haemangioma, caroli disease and vertebral haemangioma .
-In 45% of cases , the diagnosis was confirmed either by other imaging modalities e.g. MRI , CT with contrast , biochemical
evaluation , cystoscopy and biopsy in vesical mass or dinical or radiological follow up.
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CONCLUSION: A wide variety of significant or potentially significant diagnosis can be Picked up by MD NCCT performed for
suspected renal or ureteral colic. It also can suggest an alternative diagnosis for flank pain.
P20
The benefit of contrast-enhanced ultrasound in diagnosis of renal tumors (preliminary results)
Irena Sedonja, Marija Santl Letonja
General Hospital Murska Sobota, Slovenia
PURPOSE: To explore the benefit of ultrasound (US) contrast agent in distinguishing malignant renal tumors from benign lesions
on B-mode US.
PATIENTS AND METHODS: 8 patients (pts) (6m, 2f, 42-85y, mean 65y) with renal lesions found on grey-scale US were included
prospectively. Final diagnoses were renal cell carcinoma (3pts), renal pelvis carcinoma (2pts), sarcoma (1pt/those with renal pelvis
tumor), parenchimal damage following ESWL (1pt) and pseudotumor (2pts). US contrast agent – LevovistŽ (Schering), 2,5g, 300
mg/ml has been aplicated intravenously. Intermitted (Flash-echo) imaging sequences at high mechanical index and low frame rate
(1 image/2sec) has been used. Assessment of the benefit of contrast enhanced US was made.
RESULTS: In 6/8 pts important additional informations was found on contrast US images for tumor diagnosing (2 hypovascular
renal cell carcinoma, 2 renal pelvis carcinoma, 1 sarcoma) or excluding (2 pseudotumor). In pt with hypervascular renal cell
carcinoma and pt with parenchimal damage following ESWL no additional data has been found. Hypoechogenic lesion in
parenchima after ESWL could be even considered as the tumor.
CONCLUSION: According to these preliminary results US contrast media seem to be beneficial in differentiating between renal
benign lesions and malignant tumors on B-mode US.
P21
Evaluation of blunt traumatic bladder rupture by CT cystography
Luana Stanescu MD, Joel Gross MD, Hunter Wessells MD*, Emily Meshberg BS, Lee Talner MD
Departments of Radiology and Urology*, Harborview Medical Center, University of Washington, Seattle, WA
PURPOSE: Determine the accuracy of CT Cystography (CTC), frequency and severity of hematuria, and mechanism of injury in
large series of patients with bladder rupture. Describe classic findings and pitfalls in interpretation of CTC.
MATERIALS AND METHODS: Over 1000 CT cystograms were performed over a 6 year period in patients who sustained blunt
trauma. Images and reports of CTC were reviewed for 89 patients who were diagnosed with bladder rupture clinically and/or
radiographically. Accuracy was determined. A number of pitfalls in the evaluation of CTC were identified that could lead to
diagnostic confusion or error.
RESULTS: Mechanisms of bladder rupture were: 42% motor vehicle crash, 19% pedestrian vs. moving vehicle, 15% blunt trauma
to abdomen, 11% motorcycle crash, 8% fall, and 5% miscellaneous.
Of 73 patients with bladder rupture for whom data was available, 70/73 had large amount of hematuria (> 30 RBC/HPF), while only
3/73 had lesser degrees of hematuria ( 3-30 RBC/HPF). No patients had normal urinalysis. Sensitivity and specificity were 92% and
99.6% for intraperitoneal bladder rupture, and 100% and 99.3% for extraperitoneal bladder rupture, respectively.
CONCLUSION: CT Cystography is an effective tool for evaluating blunt bladder trauma. Awareness of common pitfalls can avoid
diagnostic error.
P22
Misleading gastrointestinal symptoms in renal carcinoma patients
Frkovic Marija*, Frkovic Marijan**, Kos Ivan*, Kralik Marko*, Tomić Dobrila*;
* Dpt of Diagnostic and Interventional Radiology, Clinical Hospital Center Zagreb, Kispaticeva 12, Zagreb, Croatia
** Dpt of Pediatrics, Clinical Hospital Center Zagreb, Kispaticeva 12, Zagreb, Croatia
PURPOSE: The aim of the presentation is to describe gastrointestinal manifestations of renal neoplasms.
MATERIALS AND METHODS: Four patients (male, age 44-76) with gastrointestinal symptoms (diarrhea, abdominal pain, melena
and ileus) are reported. None of them presented with symptoms of urinary tract. They underwent a number of diagnostic
procedures: plain radiography, ultrasound, intravenous urography, angiography and/or CT. Gastroduodenoscopy was preformed in
one patient.
RESULTS: Radiological diagnosis in all four patients was renal tumor. The diagnosis was confirmed after pathohistological analysis
in three patients (one patient refused further treatment): two tumors were renal cell carcinoma and one was anaplastic carcinoma of
the renal pelvis. Plain radiographs were done in all four cases showing jejunal loops paresis, soft tissue shadow and/or ileus.
Barrium study and barrium enema were done in one patient showing duodenal stenosis with ulcers and irregularities of the hepatic
flexure of the colon. Ultrasound was preformed in all patients and showed renal masses, seen also by intravenous urography.
Renal angiography revealed neoplastic vascularization. The radiological diagnosis was confirmed by CT studies in all four cases.
CONCLUSION: Gastrointestinal symptoms may be the only clinical presentation of the renal tumors. In these cases the radiological
diagnosis is difficult and sometimes accidental.
P23
Colour Doppler Ultrasound Assessment of the Inferior Vena Cava in Patients with Renal Cell Carcinoma
Correlation with intra-operative findings
Mojca Glusic1, Bojana CernelC1, Miro Mihelic2
1Clinical Radiology Institute, 2Clinical Department of Urology, University Clinical Centre Ljubljana, Slovenia
OBJECTIVE: To assess the diagnostic accuracy of colour flow Doppler ultrasound in diagnosing VCI extension of tumor thrombus
in patients with renal cell carcinoma.
MATERIALS AND METHODS: In the period from December 2002 to August 2004 tumor thrombus infiltration of VCI was diagnosed
preoperatively in 5 patients suffering from renal cell carcinoma using colour flow Doppler ultrasound. We reviewed the ultrasound
reports and compared them with the intraoperative findings.
RESULTS: Tumor thrombus extension into the VCI was present in 5 patients. In one there was also atrial extension. Colour flow
Doppler ultrasound correctly diagnosed VCI extension of tumor thrombus in 4 patients and correctly predicted the cranial extent of
the tumor thrombus in all 4 patients.
142

CONCLUSION: Colour flow Doppler ultrasound correctly detected the tumor and it’s extension within the inferior vena cava and
right atrium in 80% of the cases.
P24
Complications of renal transplantation: emergent imaging evaluation
Navalho M, Mascarenhas V, Vˇtor L, T vora I
PURPOSE: To describe the complications of renal transplantation, highlighting those in which emergent imaging evaluation can
have a crucial role.
MATERIALS AND METHODS: The most frequent complications of renal transplantation include perinephric fluid collections,
decreased renal function and abnormalities of the vasculature, collecting system and renal parenchyma. Vascular complications are
potentially catastrophic and can result in rapid loss of the transplant allograft. Emergent Doppler may identify the cause of the
dysfunction and allow intervention in a timely manner.
RESULTS: We review and outline the complications of renal transplantation, including hematomas, urinomas, lymphoceles, acute
and chronic rejection, renal artery stenosis and renal vein thrombosis.
CONCLUSION: Given the prolonged survival now possible for renal transplant recipients, it is increasingly important to use noninvasive
methods of screening these patients. Ultrasound in general and Doppler ultrasound in particular, in the setting of emergent
evaluation, can easily detect treatable causes of allograft failure.
P25
Is the radiation dose increasing in uroradiology?
Dahlman,Pär (MD); Jangland,Lars (MSc); Magnusson, Anders (MD,PhD)/Uppsala University Hospital / department of Oncology,
Radiology and clinical immunology (ORCI)
PURPOSE: To investigate the change of the panorama of uroradiogical examinations (IVP and CT) between 1992 and 2004 and
the associated change in the effective- and collective effective radiation dose.
MATERIALS AND METHODS: All investigations performed since 1992 are searchable in our RIS. The number of IVP and the
number of CT of the urinary tract referred from the urology department was compared from 1992 to 2004. The effective dose of the
different examinations as well as the collective effective dose was calculated.
RESULTS: The number of IVP decreased from 824 1992 to 584 2004 and the number of CT examinations increased from 133 to
767. The increase of CT examinations was rapid between 2001 and 2004, from 289 to 767 whilst the number of IVP decreased
from 921 to 584.
The effective dose was 2,5-3,5mSv to patients undergoing IVP and 6mSv to patients undergoing CT 1992 compared to 10-14mSv
2004. The collective effective dose increased from 3,5 manSv 1992 to 11,9 manSv 2004.
CONCLUSION: The number of CT examinations and the collective effective dose increased rapidly between 2001 and 2004. Is this
increased radiation dose really justified?
P26
Imaging findings in urethra posterior injuries
Requejo I., Fernández P., Fernández L., Méndez C., Crespo C.,Ponce J. Hospital Juan Canalejo. La Coruńa.Spain.
PURPOSE: to review urethrographic and CT findings in urethral injuries.
MATERIAL AND METHODS: We retrospectively reviewed radiological data of patients diagnosed at our institution of urethral
damage during the last 10 years. CT exams and/or retrograde urethrography were performed in all pelvic traumatisms suspicious of
associated urinary injuries.
RESULTS: direct or indirect signs of urethral damage were found in all cases. Specific findings were: -elongation of the urethra with
elevation of the prostatic apex (type I). -extravasation of contrast material above / below the urogenital diaphragm (type II/III).
Indirect signs were: -obscuration of the prostatic contour. -Distortion/haematoma of the ischiocavernous, bulbocavernous or
obturador internus muscle. -Infiltration of the uogenital diaphragm fat plane. CONCLUSION: urethral posterior injuries are among
the most serious urinary tract traumatic lesions because of the potential risk of stricture, incontinence and impotence. Blood at the
meatus or inability to void suggest the lesion but imaging studies are mandatory to confirm the diagnosis, as any attempt to pass a
catheter can increment the damage. Radiologist should be aware of direct and indirect sign and classification of urethral injuries to
allow a prompt evaluation and appropriate management.
P27
Integrated Imaging in the evaluation of Renal post-transplantation complications
M. Atzori, G. Regine, De Paulis P*, A. Cortese, L. Adami Departemnt of Radiology,* Department of Nephrourology, S. CAMILLO
Hospital, Rome, ITALY
PURPOSE:to evaluate the diagnostic impact of the integrated imaging: echocolordoppler,contrast enhanced ultrasound and
Magnetic Resonance Angiography (MRA) in renal post-transplantation complications
MATERIALS AND METHODS:between November 2003- January 2005, 52 patients with renal transplantation have been evaluated
with baseline ultrasound, echocolordoppler,contrast enhanced ultrasound (USCA) and MRA. USCA was performed after 2,5 ml of II
generation ultrasound agent (Sonovue, Bracco, Italy) injection, using CCI software (Acuson, Siemens, Germany); MRA was
performed with 1,5 T scanner (Gyroscan, Philips, Holland), before and after paramagnetic contrast media infusion with
parenchymal and vascular evaluation using TSE T1, T2 and FFET1 sequences, with MIP reconstructions, respectivly.
RESULTS: Stenotic lesions of vascular anastomosis were identified at echocolordoppler in 29 patients that were corfirmed by MRA
(13 not hemodynamically significant stenosis, 16 kinkings). 20 patients showed nephroparenchymal diseases at echocolordoppler
and USCA with MR similar findings in 18 patients. In 8 patients, with perirenal fluid collection the findings of both techniques were
similar. In only two patients diagnostic traditional Angiography was performed.
CONCLUSION: the integrated imaging depicts clearly both vascular and parenchymal complications in renal transplantation; the
techniques are less invasive with good patients’ tolerance and optimal diagnostic accuracy
P28
Testicular masses in association with congenital adrenal hyperplasia: MR features compared with sonographic findings
H.M. Suliman1, N.M.M.L. Stikkelbroeck2, G.J. Jager2, J.G. Blickman2, B.J. Otten2, A.R.M.M. Hermus2;
1:St.Lucas Andreas Hospital Amsterdam, The Netherlands, 2:University Medical Center Nijmegen, The Netherlands
143

PURPOSE: To evaluate and describe the imaging findings of testicular “adrenal rest tumors” in male patients with congenital
adrenal hyperplasia (CAH).
MATERIALS AND METHODS: Seventeen patients with CAH due to 21-OH deficiency were evaluated. All patients underwent
scrotal ultrasound (US), with color Doppler, and in 16 patients MR was performed. T2W and T1W images pre and post contrast
were obtained.
RESULTS: In 6 of the 17 patients the lesions were palpable. US revealed lesions in 16 of 17 patients (94%). The size varied from 2
mm to 40 mm. In 10 patients the lesions were hypoechoic and in 6 they were hypoechoic with hyperechoic reflections. All lesions
were located against the mediastinum. Acoustic shadowing and well-defined margins were present in 16 cases (Fig. 1).
Hypervascularity was seen in 4 lesions (Fig. 2). MR revealed lesions in 15 of 16 patients. All lesions were isointense on T1W, and
hypointense on T2W images. The lesions were clearly defined, homogeneous and located adjacent to the mediastinum testis. After
iv of Gadolinium all lesions demonstrated strong enhancement (Fig. 4 and Fig. 5). None of the lesions showed a capsule or
pseudocapsule.
CONCLUSION: Testicular lesions are common in CAH and have characteristic US and MR features. They are often multifocal,
bilateral and are found around the mediastinum testis. US monitoring will be adequate for diagnostic evaluation.
P29
Testicular torsion - diagnosis by colour duplex sonography
Dubravka Vidmar, Alenka Višnar Perovic; Institute of Radiology, University Medical Centre, 1525
Ljubljana, Slovenia
PURPOSE: Testicular torsion is a true surgical emergency due to occlusion of the efferent and/or afferent blood vessels with
consequent ishaemia following within the next four hours.This condition requires emergency operation and can be diagnosed by
colour duplex sonography which excludes other causes of acute scrotum: inflammation, traumatic testicular rupture and some other
rare conditions, which usually do not necessitate surgery.
PATIENT AND METHOD: A 29-year old man with a history of sudden and severe right sided scrotal pain was admitted to the
urology department. After a three day treatment for orchoepididymitis the condition didn't recede so an US examination was
performed.
RESULTS: The B-mode image showed an enlarged hypoechogenic and nonhomogeneous right testis. Colour duplex sonography
demonstrated a complete absence of venous and arterial blood flow. The left testis was normal in the B-mode image and had
normal perfusion as well. The diagnosis of torsion was confirmed operatively. Semicastration was performed because testicular
viability was completely lost.
CONCLUSION: Colour duplex sonography is a rapid and effective method to confirm or exclude testicular torsion as a cause of
acute scrotum. It improves reliability of decision for prompt surgical correction and prevents semicastration.
P30
The effect of external scrotal cooling on the viability of the torsed testis in rats
Mahmoud Haj , Haim Farhadian, Norman Loberant , Shaul Shasha , Western Galilee Hospital, Nahariya, Israel
PURPOSE: To evaluate external scrotal cooling in preserving testicular viability after spermatic cord torsion in rats.
MATERIALS AND METHODS: 100 adult male rats were divided into ten groups. Eight groups underwent clockwise torsion of 1080
of the right testis around its longitudinal axis, for either four or eight hours. External scrotal cooling was applied during the torsion
period in four groups. Half of the rats were sacrificed at the end of the torsion period, while the other rats underwent detorsion and
were sacrificed two weeks later. All testicles were excised for histology.
RESULTS: Histology showed that external cooling decreased both immediate and late damage to the testis caused by torsion. A
similar degree of injury was found in the contralateral testicle in rats after torsion of the right testicle for 8 hours with application of
external cooling and detorsion.
CONCLUSION: External scrotal cooling is effective in preserving the viability of the torsed testis in rats. The injury of ischemiareperfusion,
although reduced by external cooling, may endanger the contralateral testis as well, if the duration of torsion is longer
than 4 hours. With increased duration of torsion, orchiectomy should be considered. This treatment may reduce the injury in
humans awaiting surgery.
P31
Imaging findings of complications of prostate cancer therapy
Requejo I. (1), Seoane M. (1), Gulias D. (1), Fernandez P. (1), Garcia Figueiras R (2), Crespo C. (1);
1. Complejo Hospitalario Juan Canalejo. La Coruńa, Spain, 2. Complejo Hospitalario de Santiago de Compostela. La Coruńa,
Spain
PURPOSE: To present the radiological findings of the complication of prostate cancer therapy.
MATERIALS AND METHODS: A review of the imaging findings associated with the complications of prostate cancer treatment was
performed. Retrograde and voiding cystourethrography, and CT are routinely performed at our in institution as part of the follow-up
protocol for prostate cancer. Other imaging techniques are added if necessary.
RESULTS: Lymphoceles, rectal and ureteral injuries, leaks and strictures at the anastomotic site were the main complications when
a surgical approach was developed. Radiation cystitis and proctitis, rectal ulceration and rectourinary fistulas were found when
radiation therapy was performed. Incontinence and erectile dysfunction, although commonly encountered after radical
prostatectomy could also appear as a long term complication of radiation therapy.
CONCLUSION: Prostate cancer is the second leading cause of cancer in men with a 5-year survival rate of 98%. Radical
prostatectomy and radiation therapy are the most common treatment options used. Several complications of these treatments have
been described. Recognition of the imaging findings associated prompt intervention and treatment modification improving survival
rate.
P32
Is antibiotic prophylaxis necessary before TRUS guided transrectal prostate biopsies? Results of urine and blood cultures
of patients who have undergone prostate biopsy without antibiotic prophylaxis
Tansel Inal, Eriz Ozden, Ahmet Tuncay Turgut*, Murat Çilođlu, Sadettin Küpeli
Departmeny of Urology, University of Ankara, School of Medicine, Ankara
144

*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara
PURPOSE: To evaluate the necessity of antibiotic prophylaxis and to determine the type of microorganisms detected in blood and
urine cultures after transrectal ultrasound (TRUS) guided transrectal prostate biopsies.
MATERIALS AND METHODS: The study group included 28 men who had undergone TRUS guided 8 core systematic prostate
biopsy by transrectal route. Patients did not use fleet enema and any antibiotic prophylaxis before the biopsy procedure. Blood
cultures were obtained 5 minutes after the biopsy whereas urine cultures were obtained after 30 minutes. Results of the blood and
urine cultures were evaluated in order to determine infection rates. Oral ciprofloxacin was started just after the cultures.
RESULTS: Enterococcus coli (E. Coli) was identified in the urine cultures of 2 (7%) patients. Pathogenic microorganisms identified
in the blood cultures of 8 (28.6%) patients were E. Coli for 7 patients and Streptococcus for 1 patient respectively.
CONCLUSION: After TRUS guided transrectal prostate biopsy pathogenic microorganisms, the great majority of which are E. Coli,
are identified at blood cultures with a high rate. These results show that antibiotic prophylaxis is necessary before TRUS guided
transrectal prostate biopsy and the antibiotic used should mainly be effective on E. Coli.
P33
Illustration of TRUS findings of benign peripheral zone lesions which mimic prostate cancer sonographically
Eriz Ozden, Ahmet Tuncay Turgut*, Kadir Türkölmez, Ozdemir Erdođan, Sümer Baltacý
Departmeny of Urology, University of Ankara, School of Medicine, Ankara
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara
PURPOSE: To illustrate the spectrum of transrectal ultrasonography (TRUS) findings of benign lesions within the peripheral zone of
the prostate gland which have hypoechoic sonographic patterns mimicking prostate cancer.
MATERIALS AND METHODS: We reviewed the TRUS examinations and histopathological results of 1085 men who had
undergone TRUS guided prostate biopsy. Lesion biopsies were performed in addition to systematic sampling. TRUS findings
detected during the lesion biopsies with benign histopathological
results were illustrated.
RESULTS: The most frequent histopathogical results of the biopsies for benign lesions detected by TRUS were focal prostatitis,
glanduler atrophy and normal prostate tissue. On the other hand, the most frequent TRUS findings noted at the lesion biopsies with
benign histopathological outcome were focal nodular or diffuse regional hypoechogenicity of the peripheral zone.
CONCLUSION: Hypoechoic peripheral zone lesions with benign histopathological diagnosis are frequently detected during TRUS.
In this study TRUS findings of these lesions have been presented.
P34
Imaging findings of ureteroceles
Eriz Ozden, Ahmet Tuncay Turgut*, Cihan Demirel, Tarkan Soygür, Nihat Arýkan
Departmeny of Urology, University of Ankara, School of Medicine, Ankara
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara
PURPOSE: To present the imaging findings of ureteroceles with special regard to the real time ultrasonography (US) examination
for the differential diagnosis from other paraureteral lesions.
MATERIALS AND METHODS: We present a review of the preoperative imaging examinations of 14 ureterocele patients. All
patients were examined with intravenous urography (IU) and US. After the detection of a cystic mass at the distal end of the ureter
by US examination, continuous US images were obtained in order to visualize the change of the diameter of the cystic mass during
ureteral peristaltic.
RESULTS: In 12 of the 14 patients, the typical expansion of the distal ureteral cystic mass during ureteral peristaltic was shown by
continuous US imaging. IU and US images and intraoperative images of the typical lesions are presented.
CONCLUSION: The expansion of the cystic mass (saccular dilatation) of the distal ureter during US examination is a characteristic
finding of ureterocele that can be used for differential diagnosis from other paraureteral lesions.
P35
Intratesticuler varicocele
Eriz Özden, Ahmet Tuncay Turgut, Evren Süer, Önder Yaman.
Departmeny of Urology, University of Ankara, School of Medicine, Ankara
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara
PURPOSE: Intratesticular varicocele is a rare entity which may cause infertility. Management includes surgery. We report 2 patients
with intratesticular varicocele presenting typical ultrasonography (US) and color Doppler imaging findings.
MATERIALS AND METHODS: Gray scale US, color and power Doppler and pulse wave Doppler examinations performed on two
patients are presented. The examinations were performed in supine and erect positions at rest and during Valsalva manoeuvre.
RESULTS: Gray scale US revealed anechoic tubular intratesticular structures at the left testis in both patients. During Valsava
manoeuvre, the increase of the calibration of the intratesticular venous structures and continuous reverse flow were identified by
color and pulsed Doppler examinations.
CONCLUSION: Intratesticular varicocele is a rare entity which can be diagnosed by color Doppler US.
P36
The evaluation of the efficiency of periprostatic nerve blockade in TRUS guided repeat biopsies
Eriz Özden, Ahmet Tuncay Turgut*, Çađatay Göđüţ, Asým Özayar, Sümer Baltacý
Department of Urology, University of Ankara, School of Medicine, Ankara
*Department of Radiology, Ankara Research and Training Hospital, The Ministry of Health, Ankara
PURPOSE: To evaluate the efficiency of periprostatic nerve blockade for lessening pain due to transrectal ultrasound (TRUS)
guided rebiopsy.
MATERIALS AND METHODS: The study group consisted of thirty consecutive patients rebiopsied who underwent their previous
TRUS guided prostate biopsies without local anesthesia. The injection of 10 ml local anesthetic by TRUS guidance to Denonvilliers’
fascia at the level of the prostatic base bilaterally was followed by a 15 core systematic prostate sampling. After the procedure,
patients were requested to complete a questionnaire regarding the comparison of pain they experienced with that of the previous
145

iopsy by the terms; “more”, “equal”, or “less”, and if less was additionally subgraded as “minimally”, “moderately” or “severely” less
in terms of the degree of the difference.
RESULTS: All patients (100%) reported that the rebiopsy procedure performed after local anesthetic injection caused less pain in
comparison with the previous biopsy. The reported degree of difference for pain was minimal for 5(17%), moderate for 9(30%) and
severe for 16(53%) patients.
CONCLUSION: Periprostatic local anesthetic injection supplied significantly less pain during a 15 core repeat prostate biopsy in
comparison to previous prostate biopsies performed without the application of local anesthesia.
P37
Evaluation of the cause of patient discomfort during TRUS guided prostate biopsy by the comparison of the effect of
periprostatic nerve blockade on pain due to probe insertion and on pain related with the penetration by the biopsy needle
Eriz Ozden, Ahmet Tuncay Turgut*, Çađatay Göđüţ, Kerem Kutman, Kadri Anafarta
Department of Urology, University of Ankara, School of Medicine, Ankara
*Department of Radiology, Ankara Research and Training Hospital, Ministry of Health, Ankara
PURPOSE: To analyze patient discomfort during transrectal ultrasonography (TRUS) guided prostate biopsy and evaluate the
effect of periprostatic nerve blockade on different phases of the procedure.
MATERIALS AND METHODS: 50 men who underwent TRUS guided prostate biopsy were randomized into two groups. The
procedure was performed without local anesthesia in group A(n=25) whereas periprostatic infiltration of 10 ml of lidocaine was
performed in group B(n=25). All patients were requested to assess the discomfort they experienced separately as pain due to probe
insertion (P1) and pain due to penetration by the biopsy needle during the sampling procedure itself (P2) by an 11-pointed visuallinear
pain scale.
RESULTS: Mean scores for P1 and P2 were 3.88 (SD:1.87) and 4.16(SD:1.62) in group A (p=0.576) and 3.96(SD:1.79) and
1.36(SD:1.15)(p

PURPOSE: to evaluate the role of post-contrast gradient T1WI in evaluation of urinary bladder carcinoma by comparing it with
T2WI and post operative histopathology.
Patients & Methods: 55 patients with histology proven urinary bladder carcinoma underwent preoperatively axial T2WI and post
contrast axial gradient T1WI MR imaging at 1.5T (Signa horizon LX echo speed; General Electric Medical System). These results
were compared with post operative histopathology as regard local tumor staging.
RESULTS: 15/55 cases had muscular invasion (stages T2 & T3a). Compared to histopathological examination, 9/15 (60%) was
correctly assessed by T2WI and 10/15 (67%) cases by post-contrast gradient T1WI. Over staging was the most frequent problem.
In stage T3b 25/33 (76%) was correctly stage by T2WI and in 26/33 (79%) post-contrast gradient T1WI. Stage T4a was present in 7
cases, 6 cases were correctly assessed by T2WI (86%) and all cases (100%) with post-contrast Axial gradient T1WI. The overall
accuracy was (74%) by T2WI MRI and (79%) by post-contrast gradient T1WI.
CONCLUSION: Post-contrast gradient T1WI is only slightly more accurate than plain T2WI in overall local staging.
P41
MR imaging in the histologic characterization of testicular tumors
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, Th. Vadivoulis1, Ath. Pappas2, N. Sofikitis2, S. C. Efremidis1;
1Department of Clinical Radiology, 2Department of Urology, University Hospital of Ioannina. Greece
PURPOSE: To investigate the potential role of magnetic resonance (MR) imaging in the preoperative characterization of the
histologic type of testicular tumors.
MATERIALS AND METHODS: MR imaging of the scrotum was performed in 15 patients with histologically proved testicular tumors.
We obtained T2-and T1-weighted sequences, before and after intravenous administration of gadolinium chelate. The examinations
were performed on a 1.5 T magnet system, with the use of a surface coil. Differentiation between seminomatous from
nonseminomatous testicular tumors was attempted, based on MR imaging findings and more specifically on the signal intensity and
lesion homogeneity or heterogeneity. MR results were correlated with histologic findings.
RESULTS: Histologic examination revealed 16 testicular tumors in 15 patients: 8 seminomas, 6 nonseminomatous tumors, 1 IGCN
and 1 lymphoma. MR imaging was correct in 73% (11/15) of the cases in the differentiation between seminomatous from
nonseminomatous testicular tumors: the preoperative characterization of the histologic type was correct for 6 cases of seminomas
and 5 cases of nonseminomatous testicular tumors.
CONCLUSION: MR imaging may be a potential tool in the preoperative characterization of the histologic type of testicular
neoplasms. However, a larger number of patients are needed to support the above findings.
P42
Case report: presentation of splenogonadal fusion, a rare deformity
Lyssiotis Ph.*, Constantinidis F.*, Anastopoulos I.*,
Liakouras Ch.**, Tsines G.*, Kalikatzaros E.*, Malahias G.*
*Radiology and U/S department
**2nd Urology Department, Athens Medical School
Sismanoglion General Hospital, Athens, Greece
CONTENT: A 20-year old youngster (after watching a TV programme about testicular tumours!) palpated a non-tender, hard
testicular nodule. He was later admitted to the urology outpatient department of our hospital for further investigation. The clinical
examination revealed a small, hard nodule at the lower pole of the left testicle. The gray-scale and colour Doppler U/S showed the
presence of a well-defined, smoothly marginated, hypoechoic lesion (0,5 X 1 cm) with rich vascularity resembling a malignant
tumour for which the patient underwent inguinal orchiectomy.
The histopathological results of the removed left testicle fortunately revealed the presence of a fused gonad with ectopic splenic
tissue which formed a distinct encapsulated mass inside the tunica vaginalis and the absence of a tumour.
Concluding, it should be emphasised that one should always bare in mind that in young males with congenital deformities, a
testicular mass might be proved to be splenogonadal fusion.
P43
Magnetic resonance imaging of normal and benign conditions of the urinary bladder
J. Manavis, E. Kaldoudi, P. Antoniou, S. Deftereos, S. Touloupidis; School of Medicine Democritus University of Thrace, Greece
PURPOSE: To review a spectrum of MR features in normal and benign conditions of the urinary bladder and to study the magnetic
resonance tissue characteristics of urinary bladder structures in 1.0T in order to determine optimal imaging parameters for
enhanced contrast in depicting the bladder wall against fat and urine.
MATERIALS AND METHODS: 10 normal subjects and 15 patients underwent MR scans at 1.0T. Relaxation times of fat, bladder
wall and urine were measured using a two-point imaging method. The values of relaxation times were used to determine imaging
parameters for the optimum imaging of the bladder wall. Based on calculated relaxation time values contrast curves were plotted for
bladder-wall and fat as well as for bladder-wall and urine for various pulse sequences.
RESULTS: Based on the calculated contrast curves for the representative example of the spin-echo sequence, maximum T1
contrast of the bladder wall with regard to urine and fat was achieved for repetition times in the range of 620-740 ms, while
maximum T2 contrast was achieved for effective echo times in the range of 80-100 ms.
CONCLUSION: Sequence optimization allows normal and/or hypertrophic bladder wall to be distinguished from inflammation and
congestion on the basis of signal intensity variations and/or T1 and T2 relaxation parameters.
P44
Imaging of urinary bladder hernias
Bacigalupo LE 1, Bertolotto M 2, Barbiera F 3, Pavlica P 4, Lagalla R 3, Pozzi Mucelli RS 2, Derchi LE 1.
1) DICMI – Radiologia, University of Genova, Largo R. Benzi, 8, Genova I-16132, Italy.
2) Department of Radiology, University of Trieste, Trieste, Italy.
3) Department of Radiology, University of Palermo, Palermo, Italy.
4) Department of Radiology, Ospedale Sant'Orsola-Malpighi, Bologna, Italy.
PURPOSE: Bladder hernias are relatively frequent (about 3-10% of inguinal hernias) but this pathology may be unrecognized or
overlooked. In this work we present the imaging findings of this particular type of abdominal hernias.
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MATERIALS AND METHODS: Bladder hernias were collected with a retrospective review of the author’s case databases.
RESULTS: Many different types of bladder hernias were retrieved in examinations obtained for different reasons and with various
modalities (urography, cistography, ultrasound, CT, MRI, scintigraphy). The vast majority of bladder hernias were observed
involving the inguinal canal, among other types also one ischiorectal hernia was observed. Ultrasound was often the first imaging
modality obtained for the evaluation of a scrotal mass and is able to correctly identify the pathology. Urography may determine false
negative examinations due to the supine position of the patient and the lack of hernia opacification with contrast media. At CT,
bladder hernias represent often an incidental finding. During bone scintigraphy, as bladder hernias may be misinterpreted as bone
lesions.
CONCLUSION: The differential diagnosis of abdominal hernia has to include bladder hernias since correct identification is required
for proper surgical treatment.
P45
Calculosis of the urethra as a consequence of congenital anomalies of the urinary tract
Ziva Zupancic, Darja Babnik Peskar; Department of Radiology, University Medical Centre Ljubljana, Slovenia
OBJECTIVE: Calculi in urethra are rare. Clinical symptoms are non-specific and diagnosis can be difficult. We present two males
with congenital urinary tract anomalies and calculi in the urethra.
PATIENTS AND METHODS: Patient 1: 14-year-old boy with neurogenic bladder due to meningomyelocele had urethrocutaneous
fistula following urethral surgery. Urethroscopy revealed a stricture of the bulbar urethra. Imaging: Retrograde urethrocystography
showed an anterior urethral diverticulum with cutaneous fistula, penobulbar stricture, and dilated prostatic urethra filled with
radiolucent calculi.
Surgery: Urethrotomy revealed calculi in the urethra. The calculi were removed, the fistula excised, the stricture and diverticulum
opened, and urethroplasty done.
Patient 2: 26-year-old male, who had extrophy of the bladder and epispadia of the urethra at birth followed by corrective surgery,
was evaluated for incontinence. Urethroscopy revealed a stricture of the distal urethra. Imaging: The retrograde urethrocystography
showed a distal urethral stricture and a diverticulum proximal to it, filled with a faintly calcified large stone. Surgery: Urethrotomy
revealed a stricture and diverticulum with stone in the distal urethra. The stone was removed, the stricture and diverticulum
corrected, and urethroplasty done.
DISCUSSION: Calculi of the urethra, radiopaque or radiolucent, are usually located in the urethral lumen proximal to a stricture or
in a diverticulum, as they develop at the sites of urinary stasis. In diagnosing, retrograde urethrocystography is important because
endoscopic diagnosis can be difficult or prevented by the urethral stricture or narrow neck of the diverticulum, and as radiolucent
calculi are invisible on a radiograph. Congenital anomalies can predispose to the urethral calculosis.
P46
Novel nurse led prostate biopsy service
Moussa, SA. Consultant Radiologist Innes,A RMN,RGN. Urology Specialist Nurse Practitioner.
Davis,G RGN. Urology Specialist Nurse Practitioner. Western General Hospital, Edinburgh, Scotland Uk
OBJECTIVES: TRUS guided prostate biopsies are traditionally carried out by medical staff. This commitment had a significant
impact on medical staff time (262 biopsies were performed from April 2003 – April 2004 by Radiologists) reducing the available time
for other uro-radiological or urological procedures and increasing waiting time.
In response to this increase in waiting time, the first dedicated Scottish nurse led service was funded by South East of Scotland
Cancer Networks and established at the Western General Hospital in Edinburgh in April 2004.
Nurse practitioners were appointed and trained to carry out the procedures. Job description, training protocol / performance criteria
were agreed and developed. The training program spanned a six months period, included theoretical tutorials in basic ultrasound
physics, anatomy and pathology as well as practical training.
In the first 12 months 750 prostate biopsies were carried out by the nurse practitioners reducing the waiting time from 16 weeks to 2
weeks.
All prostate biopsy requests were triaged by protocol:
PSA LEVEL CATEGORY (waiting time)
> 20 (+ / - abnormal DRE) 1 (< 2 weeks)
10 – 20 2 (2-3 weeks)
3 –10 (< 70yrs) 3 (3-4 weeks)
5 – 10 (> 70yrs) 4 (4-5 weeks)
RESULTS: (750 patients)
Positive Histology = 345 patients 46%
Negative Histology = 315 patients 42%
High Grade PIN/ Atypia = 90 patients 12%
Complications (April 2004 – March 2005):
3 acute retentions
1 sepsis
2 haematuria
(all the above patients admitted.)
CONCLUSION: A nurse led TRUS guided prostate biopsy service is an efficient cost effective mean of reducing waiting time and an
essential procedure in the early detection of prostate cancer
P47
MRI findings of pure adenomyosis of uterus after uterine artery embolization
Sang-Woon Yoon / Diagnostic Radiology, Bundang CHA General Hospital,
Ki Whang Kim, Myeong-Jin Kim; Diagnostic Radiology, Severance Hospital,
PURPOSE: To report the MRI findings of uterine adenomyosis without fibroids (pure adenomyosis) after uterine artery embolization
(UAE), to evaluate the clinical response after UAE and to correlate the MRI findings with clinical response.
MATERIALS AND METHODS: Sixty-five women with symptomatic uterine adenomyosis without fibroids underwent UAE and
underwent follow-up MRI 3.5 months after the procedure.
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The pattern of adenomyosis was classified into three categories; symmetric, asymmetric, focal type. Uterine volume, junctional
zone thickness, and the development of necrosis were evaluated on pre- and post-UAE MRI.
Symptomatic improvement was also evaluated using a clinical symptom scale in terms of menorrhagia and dysmenorrhea.
Symptomatic improvement was correlated with MRI findings statistically.
RESULTS: After UAE, significant reduction of uterine volume (32.5%) and junctional zone thickness (51%) was noted (p

P51
Uterine Sarcomas: a retrospective study
N. Costa*, A. Félix**, T. M. Cunha***
*Department of Radiology & Hospital de Săo José, Lisbon, Portugal
**Department of Pathology & Instituto Portuguęs de Oncologia de Francisco Gentil, Lisbon, Portugal
***Department of Radiology & Instituto Portuguęs de Oncologia de Francisco Gentil, Lisbon, Portugal
PURPOSE: To describe the clinical, histological and main imagiological findings in Uterine Sarcomas.
MATERIAL AND METHODS: We retrospectively analyzed the medical records of 40 patients admitted to our institution between
1998 and 2002 with Uterine Sarcomas. Age of presentation, clinical findings, histological type and imaging data (CT, US and MRI)
were reviewed.
RESULTS: The median age of presentation was 57 years (range 38–88 years). Main clinical manifestations reported were: vaginal
bleeding (n=25; 62,5%), pelvic mass (n=7; 17,5%) and pelvic pain (n=6; 15%). Preoperative imagiological findings were retrieved in
18 patients. Uterine enlargement was present in all cases. Heterogeneous uterus was described in 14 patients (77,7%) and in 3
(16,6%) a sarcomatous tumor was suspected. Irregular uterine limits, endometrial abnormalities, and enlarged lymph nodes were
also found. Leiomyosarcoma and endometrial stromal sarcoma represented the most common histological types with 52,5% (n=21)
and 37,5% (n=15) respectively. Follow-up data was available in 38 patients. Twenty-four died from this condition. Until January
2005 survival ranged from 27–82 months.
CONCLUSION: Clinical and radiological findings associated with uterine sarcomas are unspecific. Although uncommon, Uterine
Sarcomas should be included in the differential diagnosis in older women with uterine enlargement.
P52
Spectrum of MRI findings in endometriosis
Oleaga L., Isusi M., García Figueiras R., De la Rosa J., Ibáńez T., Grande D.
Radiology Department. Hospital de Basurto. Avenida de Montevideo 18. Bilbao 48013. Spain.
PURPOSE: To analyze the different patterns of presentation and location of endometriosis on MRI.
MATERIALS AND METHODS: MRI findings were evaluated in 20 patients with clinical symptoms of endometriosis. Images were
performed on a 1.5 Tesla Magnet using a Phase-Array surface coil. MR imaging protocol included T2W Sagital, Coronal and Axial
images of the pelvis. Axial, Sagital and Coronal T1W. FATSAT images of the pelvis. Coronal T2W Haste and a 3D coronal GET1W
sequences of the abdomen. All patients underwent surgical laparoscopy to confirm the diagnosis.
RESULTS: We found ovarian endometriomas in 17 cases, in two cases the endometriosis foci were located in the abdominal wall
and in one case on the sigmoid wall. The endometrial foci were of high signal on T1W images and low signal on T2W images in all
the patients. On the 17 cases with ovarian endometriomas we found the shading effect on T2W images.
CONCLUSION: MRI is a useful imaging method to assess and characterize ovarian endometriomas and endometriosis foci outside
the ovaries.
P53
Spectrum of MRI findings in adenomyosis
Oleaga L., Isusi M., García Figueiras R., Ibáńez T., De la Rosa J., Grande D.
Radiology Department. Hospital de Basurto. Avenida de Montevideo 18. Bilbao 48013. Spain.
PURPOSE: To analyze the different patterns of presentation of adenomyosis on MRI
MATERIALS AND METHODS: Images were performed on a 1.5 Tesla Magnet using a Phase-Array surface coil. MR imaging
protocol included Axial T1W, Sagital, Coronal and Axial T2W images of the pelvis. Surgery was performed in five cases and in 7
cases we have a clinical follow up after hormonal treatment.
RESULTS: We found 8 cases of diffuse adenomyosis and four cases of focal adenomyosis.T2W images are the most useful for the
diagnosis. The lesions appeared as low intensity areas focal or diffuse with scatered high signal intensity foci.
CONCLUSION: MRI can be used to diagnose and differentiate focal from diffuse adenomyosis. It is reliable both for the detection
and for its distinction from leiomyoma
P54
Multi-detector row CT in the detection and characterization of adnexal masses
A. Ch. Tsili1, C. Tsampoulas1, O. Katsios1, K. Vlachos1, Ev. Paraskevaidis2, S. C. Efremidis1.
1Department of Clinical Radiology, 2Department of Gynecology and Obstetrics; University Hospital of Ioannina. GREECE.
PURPOSE: To evaluate the role of multi-detector row computed tomography (MDCT), with a 16-row CT scanner in the detection
and characterization of adnexal masses.
MATERIALS AND METHODS: Forty-five women with sonographically detected adnexal masses were prospectively examined.
Examinations were performed on a 16-row CT scanner. Scanning of the abdomen during the portal phase, with a detector
collimation of 16 X 0.75 and a pitch of 1.2, as well as multiplanar reformatted images were obtained to evaluate the presence of an
adnexal mass and characterization of their benign and malignant nature. MDCT findings were correlated with surgical and
histologic findings.
RESULTS: CT detected 60 of the 64 (94%) adnexal lesions seen on histologic examination, of mean diameter of 7.5 cm,
demonstrating a sensitivity of 87%, a specificity of 89%, a positive predictive value of 72% and a negative predictive value of 95% in
the characterization of ovarian masses.
CONCLUSION: MDCT is a highly accurate technique in the detection of adnexal lesions.
P55
Spectrum of imaging findings in the normal and pathologic endometrium
I. Pereira*, A. Félix**, T.M. Cunha***
*Department of Radiology – Hospital de Santarém, Portugal
**Department of Pathology Instituto Portuguęs de Oncologia de Francisco Gentil, Lisbon, Portugal
***Department of Radiology Instituto Portuguęs de Oncologia de Francisco Gentil, Lisbon, Portugal
LEARNING OBJECTIVES: To review the spectrum of transvaginal ultrasound and MR features of the normal and pathologic
endometrium with histological diagnosis correlation.
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BACKGROUND: The endometrium demonstrates a wide spectrum of imaging findings in normal, inflammatory and neoplasms. The
appearance of the endometrium is dynamic, depending on the patient’s age, phase in the menstrual cycle, pregnancy and
hormonal therapy including tamoxifen. TVUS and MRI are good imagiological modalities to evaluate endometrium.
IMAGING FINDINGS: In this presentation we illustrate the different imaging findings that allow the differential diagnosis on
endometrium thickness and endometrial tumors. Cyclic endometrium, endometrial polyps, endometritis, hyperplasia or submucosal
leiomyomas are frequent benign entities that should be recognised and disclose from other neoplasms such as gestacional
trophoblastic diseases, adenocarcinoma and endometrial stromal sarcoma that may be also responsible for endometrial thickening
or intracavitary tumors.
Other findings such as endometrial adhesions, intrauterine fluid collections are other entities in the differential diagnosis.
CONCLUSIONS: Knowledge of TVUS and MR features of physiologic, benign and malignant conditions of the endometrium
facilitates accurate diagnosis and provides adequate treatment.
P56
Adnexal lesions with suspicious criteria for malignancy by MRI
Adalgisa Guerra*; Ana Felix**; Teresa Margarida Cunha***
*Department of Radiology - Hospital Pulido Valente, Lisbon, Portugal
***Department of Pathology - Instituto Portugues de Oncologia de Francisco Gentil, Lisbon, Portugal
***Department of Radiology - Instituto Portugues de Oncologia de Francisco Gentil, Lisbon, Portugal
PURPOSE: To correlate the MR imaging findings of adnexal lesions with suspicious criteria for malignancy to histological findings.
MATERIAL AND METHODS: We review MR images of 72 women for a total of 100 imagiological suspicious adnexal lesions for
malignancy. Our inclusion MR findings for adnexal suspicious of malignancy were the “widely accepted” criteria: contrast-enhanced
solid and mixed lesions, cystic lesions with papillary projections or septal thickness >/- 3 mm, presence of ascites, peritoneal
metastasis and pelvic lymphadenopathy. We exclude nonenhanced solid lesions with very low-signal-intensity on T2WI and cystic
lesions with septal thickness

Ranka Stern Padovan 1, Marko Kralik 1, Mario Lucic 1, Ante Corusic 2;
1 Clinical Hospital Center, University of Zagreb, School of Medicine, Clinical Institute of Diagnostic and Interventional Radiology
Kispaticeva 12, Zagreb, Croatia
2 Clinical Hospital Center, University of Zagreb, School of Medicine, Department of Gynecology and Obstetrics, Kispaticeva 12,
Zagreb, Croatia
PURPOSE: The aim of the presentation is to depict difficulties in diagnosing pelvic masses on CT and MR.
MATERIALS AND METHODS: 32 patients (females, age 1-78) with abdominal pain and/or distension underwent preoperative CT
(23), MRI examination (six) or both (three). A pathologist revised 28 of 32 radiological diagnoses postoperatively. Tumor serum
markers, as well as other laboratory and relevant clinical data were available for most of the patients.
RESULTS: After radiological examination(s) diverse diagnoses were proposed based on more or less characteristic imaging
findings: ovarian tumor (four patients), pelvic inflammatory disease - PID (three patients), metastatic tumor (seven patients), uterine
(corpus and cervix) tumor (11 patients), lymphocele (two patients), changes after irradiation and chemotherapy (eight patients).
Of the 28 diagnoses revised by a pathologist 5 (18%) were misdiagnosed by the radiologist giving the false positive diagnosis of the
malignancy (two patients), one surgical transposition of the ovary as tumor and one hematoma as PID.
CONCLUSION: Many different conditions within the pelvis cause a narrow spectrum of symptoms. It is of utmost clinical importance
that the radiologist recognizes these conditions. This is possible only if sufficient patients' clinical and laboratory as well as surgical
protocols data are available.
P60
Hematocolpos: clinical presentation and imaging
N Loberant, M Herskovits, M Goldfeld, V Salamon, Department of Radiology, Western Galilee Hospital, Nahariya, Israel
PURPOSE: To review the clinical presentation and imaging findings in hematocolpos in 4 teenagers.
MATERIALS AND METHODS: 4 girls aged 11, 12, 12 and 17 presented to the emergency room with either abdominal pain or
urinary retention. None of the patients were referred because of menstrual abnormalities. All 4 girls underwent ultrasound and 3
underwent CT. One 12 year old girl also had a duodenal duplication cyst, and her hematocolpos was caused by a vaginal septum.
RESULTS: In all cases a diagnosis of hematocolpos or hematometrocolpos was made and treatment was successfully carried out.
CONCLUSION: Diagnosis of hematocolpos should be considered in young females who are referred for lower abdominal pain
and/or urinary retention. The clinician may not indicate any history of menstrual abnormalities. Sonographic examination showing a
midline, fluid-filled mass arising from the pelvis, posterior to the bladder, should suggest the proper diagnosis. The uterus is located
at the cephalic end of the mass. If the uterine cavity is distended with blood, the diagnosis is hematometrocolpos. Clinical
confirmation is generally straightforward if the obstruction is at the hymen, but if the obstruction is more proximal than an
imperforate hymen, the clinical diagnosis may be more difficult.
P61
Emergency ultrasonography in gynecologic field
Jongchul Kim, Department of Diagnostic Radiology Chungnam National University Hospital Daejeon, South Korea
PURPOSE: To define the various findings of emergency ultrasonography (US) in gynecologic disorders.
MATERIALS AND METHODS: Among 1,500 patients who received emergency US due to acute pelvic pain in our hospital during
recent 15 years, 1,000 patients with good quality of US and final diagnosis of gynecologic disease were retrospectively analyzed by
two gynecologic radiologists.
The US findings were analyzed in terms of outline, echogenecity, posterior acoustic shadowing or enhancement, solid or cystic
nature, septa, mural nodule, blood flow signals on color Doppler, hydronephrosis, ascites, g-sac, etc.
RESULTS: Changes over time of the internal structure of various echogenecity becoming predominantly anechoic at follow-up in
hemorrhagic ovarian cyst (n=184). Whirling sign in ovarian torsion (n=26). Fluid in endometrial cavity with indistinct borders of the
uterus & ovaries in PID, enlarged ovaries and dilated tubes in tubo-ovarian complexes, or flank TOA (n=119). Extrauterine
gestational sac containing an embryo in ectopic pregnancy (n=27).
CONCLUSION: Familiarity with these gynecologic US findings that cause acute pelvic pain will allow the radiologists to guide
appropriate treatment of affected patients and may eliminate the need for further imaging evaluation. It is essential for radiologists
to be well acquainted with findings of US on emergency in gynecologic field.
P62
Percutaneous drainage of kidney abscesses
Mylona S.(MD), Kokkinaki A. (MD), Thanos L. (PhD),
Stroumpouli E. (MD), Karahaliou E. (MD), Batakis N. (MD)
PURPOSE: To present the technique and discuss the indications and complications of percutaneous CT- guided drainage of kidney
abscesses.
METHOD AND MATERIALS: During a 2-year period 22 patients (14 women, 8 men) with kidney abscesses proceeded to our
department for percutaneous drainage under CT guidance. Twelve abscesses were located in the left kidney and 10 in the right. In
21 cases, we used the trocar technique for the insertion of the catheter and in one case the Seldinger technique. A pig-tail catheter
(8-14f) was placed and material for cultivation was aspirated. The catheter was removed after a mean time of 6 days when it
ceased draining and patients symptoms lapsed.
RESULTS: Twenty one abscesses were totally drained (95, 45%) and only one had to be operated. The results from the cultivation
of the abscesses material demonstrated: in 13 (61%) cases E. coli, in 6 (29%) Staphylococcus and in 2 (10%) Proteus Mir. The
only complication observed was a small subcapsular haematoma in two cases.
CONCLUSION: Percutaneous drainage under CT-guidance is a minimally invasive, safe, and effective method for the treatment of
renal abscesses.
P63
Re-audit of follow-up in patients with impaired renal function undergoing vascular imaging using contrast media
HJ Harris, S Agarwal, PWG Brown
The Northern General Hospital, Herries Road, Sheffield, S5 7AU, UK
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PURPOSE: Contrast media-induced nephropathy (CMN) occurs more frequently in patients with renal impairment. Previous audit
showed poor identification and follow-up of these patients undergoing vascular radiological procedures using intravenous contrast.
A new protocol for management and follow-up was instituted, including prehydration for patients with creatinine >150mmol/l. Audit
was repeated, to reassess follow-up and see if this creatinine level was appropriate for prehydration.
MATERIALS AND METHODS: Prospective audit was performed. All patients with impaired renal function undergoing a vascular
radiological procedure were identified and divided into 2 groups – creatinine 120-150 mmol/l or >150mmol/l. Biochemistry records
were checked for 6 weeks post-procedure for each patient and creatinine levels recorded.
RESULTS:
- 109 patients, 116 procedures.
- All patients with creatinine >150mmol/l were prehydrated.
- 82.8% had post-procedure creatinine checks. 55.2% followed the protocol.
- 25% demonstrated creatinine rise on day 2 or 3, and most were then followed up regularly.
- No follow-up occurred in 17.2% (21.5% in those with creatinine >150 mmol/l).
- The overall rate of CMN was 6.0% (9.8% with creatinine >150 mmol/l, 3.1% with creatinine 120-150 mmol/l). No patient in this
latter group suffered a permanent deterioration in creatinine that was definitely attributable to contrast.
CONCLUSION: Prehydration and creatinine follow-up after intravenous contrast in patients presenting with creatinine 120-150
mmol/l maybe unnecessary. Patients at highest risk of developing CMN are not followed up adequately. Strict adherence to the
renal protection protocol must occur in patients with creatinine >150 mmol/l.
P64
Renal cell carcinoma (RCC): is radiofrequency ablation (RFA) an effective means of treatment?
Thanos L., Mylona S., Ntai S., Kokkinaki A., Tzavoulis D., Batakis N.; Radiology Department - Red Cross Hospital of Athens
PURPOSE: To describe the efficacy of RFA in the management of renal cell carcinoma based on postoperative histological
findings.
MATERIALS AND METHODS: In a 24-month period thirty patients who suffered from RCC underwent RFA. Two different types of
electrodes were used (RITA and MIRRAS). A treatment of 15-18 minutes was performed under local anesthesia in all cases. All
patients had previously received analgesic treatment p.o. After the completion of the procedure they underwent a contrastenhanced
dual phase CT scan to check for probable complications and residual enhancement. The patients were led 24 hours later
to the operating room. Twenty-four underwent nephrectomy and six tumors resection.
RESULTS: No major complications occurred during the RFA sessions. Only a small subcapsular haematoma was noticed in one
case (3%). The histopathological evaluation of the removed specimens revealed total necrosis in 28 cases (93%) and partial
necrosis in 2 (7%).
CONCLUSION: RFA is a safe treatment modality that can be effectively applied to patients that cannot be operated, since total
necrosis is succeeded in the vast majority of cases.
P65
Percutaneous CT-guided nephrostomy: a quick and safe method which involves no radiation for the interventional
radiologist
Thanos L., Stroumpouli E., Mylona S., Ntai S., Tzavoulis D., Batakis N.; Radiology Department - Red Cross Hospital of Athens
PURPOSE: To present the indications, technique, complications and contraindications of percutaneous CT-guided nephrostomy, as
an alternative procedure to standard fluoroscopy guided nephrostomy, involving no radiation exposure for the radiologist.
MATERIALS AND METHODS: Between June 2000 and January 2005, 284 percutaneous CT-guided nephrostomies were
performed in 235 patients, at our department. Two hundred-eleven patients (90%) underwent percutaneous nephrostomy due to
obstructive uropathy. Twenty-four patients (10%) required the procedure as treatment alternative to non-obstructive urinary bladder
trauma. All patients underwent percutaneous nephrostomy with subsequent insertion of nephrostomy tube under computed
tomography (CT) guidance.
RESULTS: Percutaneous access was achieved, without major complications in all cases. The most common complication was
lumbar pain on the puncture site. In 58 patients (25%) the nephrostomy catheter was held in place until the full decompression of
the obstruction. In 24 patients (10%), with urinary bladder trauma, the catheter was dislodged after trauma convergence. In 153
patients (65%) the catheter’s placement was permanent.
CONCLUSION: CT-guided nephrostomy is a reliable, safe, fast and high-effective method, which is associated with low
complication rate and involves no radiation for the interventional radiologist.
P66
Role of multislice CT scan in evaluation of living renal transplant donors
S. Hanna, S. Abd El-Rahman, M. Shahin & H. Badawy
PURPOSE: To determine the accuracy of multidetector CT (MDCT) angiography in the evaluation of living kidney donors.
MATERIALS AND METHODS: Thirty consecutive living kidney donors (13 men, 17 women; mean age, 34.55 years) who
underwent MDCT were evaluated. CT examination was performed with 100 mL of IV contrast material at an injection rate of 3
mL/sec and a pitch of 1.5. In every case, arterial, nephrographic and excretory phase volumetric data sets were acquired at 25, 90
and 300 sec, respectively. Scans were reconstructed at 1-mm intervals for three-dimensional (3D) imaging using a volumerendering
technique. Axial CT images and 3D CT angiography were evaluated prospectively and retrospectively. Surgical
correlation for the location of primary and accessory renal arteries, early branching of the renal arteries, and renal vein anomalies
was made.
RESULTS: Ten patients were excluded because of recipient and donor health problems. Therefore, a total of 20 patients were
enrolled in a renal transplantation program. CT and surgical findings agreed in 100 % of subjects. CT and surgical findings agreed
in 100 % Sensitivity and specificity of CTA in detection of renal veins anomalies was 67% and 100% respectively and the accuracy
was 95%.
CONCLUSION: MDCT angiography is highly accurate for detecting vascular anomalies and providing anatomic information for
living donor nephrectomy.
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YP67
Post-traumatic high-flow priapism: diagnosis with MRA and treatment by selective arterial microcoil embolization (case
report)
Ahmed Farouk, MD*, Essam Abou-Bieh, M.Sc.*, Mohamed Abou El-Ghar, MD*, Yasser Osman, MD**, And Tarek El-diasty,MD*; *
Radiology Department; ** Urology Department; Urology and Nephrology Center, Mansoura University, Mansoura, Egypt
CONTENT: High-flow (non-ischaemic) priapism is an uncommon condition which results from a state of unregulated high arterial
blood flow to the cavernosal tissue, rather than obstructed venous outflow. Such high inflow and outflow spare the cavernosal
tissue the risk of hypoxia and acidosis. The condition is usually following perineal trauma with subsequent cavernoso-sinusoidal
fistula and/or pseudoaneyrsm. The diagnosis is based on cavernous blood gas analysis, color Doppler sonography, MRI and MR
angiography and internal iliac angiography. Selective vascular embolization is the treatment of choice and surgery is limited to the
cases after failure of embolization.
P68
MSCT imaging of early and late complications after renal transplantation
Lusic M, Stern-Padovan R, Hrabak M, Sjekavica I, Molnar M, Oberman B.
Clinical Institute of Diagnostic and Interventional Radiology, Clinical Hospital Center Zagreb, University of Zagreb, School of
Medicine, Zagreb, Croatia
PURPOSE: Ultrasonography and CD are methods of choice in screening for complications after renal transplantation.
The aim of this study was to show normal postoperative anatomy, and to evaluate the role of MSCT imaging in evaluation of
morphological changes in early and late complications after renal transplantation.
MATERIALS AND METHODS: Retrospective analysis of multiphase MSCT examinations performed during a 3-year period in
patients with sonographically suspect complication after renal transplantation was performed. RESULTS: Pathologic fluid
collections (hematomas, abscesses) were the most frequent early complication. Inflammatory changes seen in our patients were
suppurative pyelonephritis of the graft, and xanthogranulomatous pyelonephritis of the native kidney. Renal artery changes
(stenosis, occlusion) were detected during arterial phase, and their hemodynamic significance could be assessed. Obstructive
nephropathy was caused by stenosis of ureteral anastomosis, or urolithiasis.
Malignancies, including native kidney carcinoma, graft carcinoma and lymphoma, were also found.
CONCLUSION: Multiphase MSCT imaging in renal graft recipients enables visualization of parenchymal, perirenal, pyeloureteral,
and vascular complications, as well as evaluation of other intraabdominal and retroperitoneal pathology. It is a fast, safe, and
minimally invasive technique which provides detailed information for treatment planning.
P69
Pelvo-calyceal biomodelling as an aid to achieving optimal access in percutaneous nephrolithotomy
Radecka E, Brehmer M, Magnusson P, Palm G Magnusson A; Department of Radiology, Urology, University Hospital of Uppsala,
Sweden, IVF, Stockholm
PURPOSE: A prospective trial to investigate the benefits from three dimensional stereolithographic biomodelling produced from
Computed Tomography (CT) data, as an aid to achieving optimal access in percutaneous nephrolithiasis treatment with
percutaneous nephrolithotripsy (PCNL).
MATERIAL AND METHODS: Four patients with complex urinary calculi in the collecting system were selected. Multislice CT of the
kidney was performed. Contiguous reconstructed slice images were produced from the data volume. The data of interest were
processed to transform the raw CT data into a format acceptable to produce a biomodel. Exact plastic replicas of the pelvo-calyceal
system, and the urinary calculi were created. The biomodels were used for the morphologic assessment, preoperative planning and
surgical navigation.
RESULTS: The survey results are based on subjective opinions rather than objective data. Biomodels enhanced the ability to
visualize a patient’s unique structures before surgery. This aided the planning and rehearsal of endourological procedures.
CONCLUSION: Although this study is only a preliminary investigation we postulate that biomodelling has the advantage, of allowing
imaging data to be displayed in a physical form. This may improve treatment, preoperative planning and communication between
colleagues and patients. Limitations of the technology include manufacturing time and cost.
P70
Complications to double J-stents
Radecka E, Holmgren K, Magnusson A Department of Radiology, Urology, University Hospital of Uppsala, Sweden IVF, Stockholm
PURPOSE: Most of the double J-stents are placed endoscopically, in order to relieve ureteric obstruction, to promote ureteral
healing or as a prophylaxis against possible complications. The most common complication of ureteric J-stents is “stent syndrome”
including irritative voiding symptoms, flank pain, suprapubic discomfort and occasional hematuria. Radiology plays an important
role in the monitoring of stents and it may offer solutions for corrections of complications. The aim of this study was to determine the
incidence and type of complications occurring in J-stent treated patients.
MATERIALS AND METHODS: A retrospective analysis of the records of 112 patients treated with J-stent over a 5-year period was
performed. The main indication to J-stent treatment was urolithiasis. The J-stents were inserted by retrograde route over a
guidewire by ureteroscopy in general anesthesia.
RESULTS: J- stent insertion was successful at the first attempt in 110 of 112 procedures (98%). Complications including irritative
symptoms, urinary tract infection, hematuria, migration and encrustation were registered in 97 of the patients (87%). The most
common complication was irritative voiding symptoms occurring in 41(37%) of the patients.
CONCLUSION: Patients with double J-stent have a high incidence of urinary symptoms. However, long-term J-stenting is the only
option if open diversion is to be avoided. The findings in this study demonstrate the need of development of stents in order to
prolong the patency and to reduce the number of irritative symptoms-the development of the ultimate stent.
P71
Percutaneus insertion of double-J endoprothesis in children with ureteral stenosis or occlusions
Damjana Kljucevsek, Children's hospital Ljubljana, Slovenia Tomaz Kljucevsek,Clinical center Ljubljana, Department of radiology,
Ljubljana, Slovenia Bojan Trsinar, Clinical center Ljubljana, Department of urosurgery, Ljubljana, Slovenia
154

PURPOSE: Percutaneous treatment of ureteral stenosis or occlusions with insertion of double-J (DJ) endoprothesis is a method of
choice when endoscopic approach isn't possible.
MATERIALS AND METHODS: DJ endoprothesis was percutaneously inserted in six children, mean age 5,5years, who had
postoperative occlusions of the ureter. Three children were treated because of complex congenital anomalies of urotract and all
had previously had several surgical procedures. Two children had restenosis of pyeloureteral junction and one girl suffered a
migration of intraoperative placed DJ with stenosis of the distal part of this ureter. Percutaneous insertion of DJ was thought to be
the only way to establish connection between pyelon and bladder.
RESULTS: Percutaneous insertion of DJ endoprothesis was successful at first attempt in four children, two attemps were needed in
two children. After insertion of DJ regular ultrasound controls of DJ position and urine cultures were done. Although the children
were under antibiotic prophylaxis, one boy got pyelonephritis. One girl had spontaneously stopped hematuria. One DJ migrated in
distal part of the ureter and was successfuly pulled back into the bladder. All children are doing well and no further procedures were
needed.
CONCLUSION: Percutanous insertion of DJ endoprothesis is an option in the management of children with occlusions of the ureter,
particulary when there are no other possibilities to establish continuation between pielon and bladder.
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