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Ct mri urography
- 1. CT AND MRI UROGRAPHY DR. DEV LAKHERA
- 2. UROGRAPHY DEFINITION Urography is a radiologic technique used for the evaluation of the genitourinary system: specifically, the kidneys, ureters and bladder.
- 3. UROGRAPHIC TECHNIQUES INTRAVENOUS UROGRAPHY COMPUTERIZED TOMOGRAPHIC UROGRAPHY MAGNETIC RESONANCE UROGRAPHY
- 4. CT urography Hybrid CTU CT Urography
- 5. Hybrid CT urography CT and IVU are done together. Adv :- no reformatting needed Disadv:- Imaging at different location
- 6. CTU Protocol –Three phase protocol Unenhanced phase Nephrographic phase after 90-100 secs Pyelographic phase after 12-15 minutes 4 Phase protocol (5 min and 7.5 min)
- 8. Contrast media Omnipaque (100-150 ml non ionic contrast media at a rate of 2-4 ml/second)
- 9. Split Bolus MDCT Urography with Synchronous Nephrographic and Excretory Phase Enhancement Unenhanced Phase Nephro-pyelographic phase : 30 ml of nonionic contrast material is infused and after 10 min another 100 ml of contrast is injected ADV: Assess tract with low radiation exposure.
- 10. Image post processing techniques
- 12. Maximum Intensity Projection (MIP) Projecting the voxel with the highest attenuation value on every view throughout the volume onto a 2D image
- 13. Volume rendering technique (VRT)
- 14. Indication of CT Urography To evaluate patients with hematuria Calculi Renal / Urothelial tumors Congenital anomalies.
- 15. Renal calculi Presence, size and location of urinary tract calculi Exclude extraurinary pathologies that may mimic calculi
- 17. Renal Tumors Enhancement : Nephrographic phase Location : Renal cell carcinoma is frequently located at the periphery or near the cortico-medullary junction of the kidney as it originates in the renal cortex tumors with nephron sparing surgery
- 18. CT urogram (volume rendering ) Axial CECT
- 20. UROTHELIAL CARCINOMA Excretory phase CTU shows a soft-Tissue attenuation mass in upper left kidney with associated calyceal distortion
- 21. Coronal reformatted image MIPimage
- 23. Ureteric injury
- 24. Congenital anomalies Retrocaval ureter Ureteral duplication Crossed fused kidneys Ectopic kidneys
- 25. Fused low lying ectopic kidney
- 27. Maximum intensity projection curved planar reformation excretory phase CT urogram
- 28. Advantages of IVU over CT urography Better spatial resolution Lesser radiation dose Cheaper
- 29. Ct urography: Advantages Multidetector CT : Thin slices in single breath hold allow optimal anatomic information Isotropic MPR reconstruction Better contrast resolution
- 30. Image improvement techniques Compression Saline Infusion Diuretic Administration Patient Positioning
- 31. 34 year old lady with pain Left side of abdomen, and hydronephrosis on USG
- 32. MR Urography urinary tract obstruction Hematuria congenital anomalies surgically altered anatomy beneficial in pediatric or pregnant patients or when ionizing radiation is to be avoided
- 33. Principle urine have very long T2-relaxation time heavily T2-weighted pulse sequence generate images with high signal intensity from static fluid
- 34. Sequences Without contrast administration : Heavily T2-weighted static-fluid MR urograms Half fourier acquisition single-shot turbo spin-echo(HASTE sequence) With contrast administration with excretory T1-weighted sequences (excretory MRU)
- 35. Static fluid MR Urogram demonstrates the collecting system, ureters and bladder
- 36. Coronal static-fluid MR urogram shows obstruction of the right distal ureter in a patient with prostrate cancer
- 37. Coronal single-shot fast spin-echo image shows a metastatic lymph node
- 41. Excretory urography Gadolinium shortens the T1 relaxation time of the urine, allowing the urine to initially appear bright on T1-weighted image Dose: 0.1 mmol/kg
- 42. Effect of gadolinium excretion on T2- weighted MR urographic techniques
- 43. static-fluid MR urography MIP excretory urography after gadolinium
- 44. Advantages MRU has better contrast resolution than CT urography without radiation exposure and IV contrast administration
- 45. Disadvantages over CT Urography Longer examination times than for CT urography Decreased spatial resolution Inability to reliably depict calcifications and calculi
- 46. THANK YOU
Editor's Notes
- IVU IS THE MOST COMMONLY USED TECHIQUE , CT urography is a developing diagnostic imaging technique is progressively replacing the ivu in western contries , ROLE OF MR IN UROGRPAHY IS STILL BEING ESTABLISHED
- Two sets of
- Solution: table top with insertable grid and cassette and ceiling mounted xray tube , Scanned projection radiographic
- (100-150 ml non ionic contrast media at a rate of 2-4 ml/second) //Nephrogenic phase is after the cortico-medullary phase (50 seconds) –dye has reached the distal part of collecting duct( renal vasculature) // To evaluate urothelium from the pelvicalyceal system to the bladder // avoided due to radiation risks
- Unenhanced CT scans used for the evaluation of calculi, renal parenchymal calcifications, precontrast attenuation measurements// nephrographic phase is Neoplasm inflammatory diseases
- (Iohexol) 300mg/min
- (A) Coronal MPR image demonstrating only a small segment of the left ureter in its mid portion (B) Curved multiplanar reformation displaying a left ureteric calculus, the consequent hydronephrosis and the entire dilated ureter proximal to it in a single image regardless of opacificaion
- area of interest can be obscured the by high density material, such as bone, calcium, and oral contrast medium.---Better detect pulmonary nodules, vessels MINip areas of emphysema
- all attenuation values within a voxel are used to obtain the final image Entire volume of data and displays anatomic structures with different levels of attenuation //with bone editing///angiography , large airway abnormality
- Symptomatic indications include hematuria,
- Secondary signs obstructive urinary calculi of Hydronephrosis, hydroureter, ipsilateral renal enlargement. Calculi in unusual positions such as in calyceal divertculae
- VRT image (B) displaying the same
- Enhance ment of more than 20 HU// Require information about its location near the collecting system. ….
- Contrast-enhanced axial CT scan: (A) showing an enhancing mass in the upper and mid pole of the right kidney. CT urogram using volume rendering (B) showing distortion of the calyces by the mass lesion
- CT urogram using MIP technique (C) showing splaying, distortion of the calyces on the right side –right renal cell carcinoma
- excretory IVU shows compression of the upper left renal infundibulum
- Papillary necrosis. Coronal (A) and sagittal (B) MIP images of the left kidney demonstrate a filling defect in the superiormost calyx (arrow) secondary to sloughing of the papilla into the calyx.
- Axial CT scan of the pelvis in the excretory phase demonstrates extravasation of contrast 3D volume-rendered image of the study shows the exact location of the ureteric injury
- ureteric compression but also the IVC
- low lying ectopic kidney with fusion of both kidneys
- Volume rendered image in the excretory phase
- Duplicated collecting system with an ureterocele///dilated left upper pole and ureter (arrows) and ureterocele
- Projectional imaging technique The patient's body habitus, state of bowel preparation, and renal excretion rate are factors contributing directly to the visible radiographic contrast, and can lead to sub-optimal image quality,
- Cross section radiography, projection radiography. compromised by variables like bowel preparation, renal function and radiographic factors. three-dimensional view of the renal morphology
- Furosemide: prone position achieved higher opacification of the mid and distal ureters.
- a) Scout film KUB area shows no radio-opaque calculus. b) 30 minutes prone IVU film showing hydronephrosis with proximal hydroureter Left side. c) CTU Coronal MIP image clearly showing calculus within Left ureter.
- ionizing radiation or iodinated contrast material is to be avoided.
- treats the urinary tract as a static column of fluid--high signal intensity from static fluid in the collecting whereas lower signal intensity from parenchymal tissue is suppressed. ..Diuretic administration…. extremely fast and are performed in one breathhold
- Static-fluid MR urography does not require the excretion of contrast material and is therefore useful for
- Prostate cancer metastatis to lymph nodes
- A, Coronal T2-weighted MR image shows low-signal intensity filling defect ( Arrow ) in right renal pelvis. B, T2-weighted static-fluid MR urograph confirms presence of filling defect (Arrowhead ) in renal pelvis
- A, Unenhanced CT urographic scan through pelvis shows thickened postpar tum uterus ( arrow).B,Pyelographic phase CT urographic scan shows multiple filling defects ( Arrowhead ) due to blood clots in bladder.
- C, Coronal reformation of pyelographic phase CT urographic scan shows absence of contrast excretion from right renal collecting system ( arrow).D,Coronal T2weighted static-fluid MR urograph shows filling defects (arrowhead) suggestive of blood clots in pelvicaliceal system of kidney.
- Coronal MIP image from excretory MR urographic data
- The T2 shortening effect of gadolinium prevents successful application of static-fluid MR urography during the excretory phase after the intravenous administration of gadolinium-based
- Static fluid mru shows the presence of urine rather than excretory function