Audit of split-bolus CT urography for the investigation of haematuria over a 12 month period at two district general hospitals

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1 Audit of split-bolus CT urography for the investigation of haematuria over a 12 month period at two district general hospitals Poster No.: C-1349 Congress: ECR 2010 Type: Educational Exhibit Topic: Genitourinary Authors: L. D. Wheeler, R. Clements, M. Robinson; Newport/UK Keywords: CT Urography, Haematuria, Audit DOI: /ecr2010/C-1349 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 18

2 Learning objectives To outline the technique of split-bolus CT urography (CTU) for the investigation of haematuria. To present an audit of all 338 patients investigated with CTU over a 12 month period in two hospitals along with imaging and pathological correlation. To discuss, with illustrations, positive findings, equivocal findings and significant extra-renal tract pathology. Background The European Society of Urogenital Radiology (ESUR) published clinical guidelines for MDCT urography in 2008 [1]. Their findings included: A definition of CTU as a "CT examination optimised for the imaging of kidneys, ureters and bladder" which can be performed in different ways but must include a delayed, contrast-excretion phase. CTU performs 'significantly better' than IVU alone and 'at least as good' as combined IVU and retrograde studies for diagnosis of upper tract Transitional Cell Carcinoma (TCC) in high-risk individuals. CTU is justified as a first line test for macroscopic haematuria. We introduced split-bolus CTU across two hospital sites, in South East Wales, in early 2007 for the investigation of haematuria, replacing the IVU. Local indications for a CTU from haematuria clinic: Normal ultrasound and cystoscopy but patient has 1 or more of the following: smoking histroy, relevent occupational exposure, history of pelvic irradiation or previous cyclophosphamide treatment. Positive/atypical urine cytology Indeterminate renal mass Staging of a known bladder TCC. We implemented a simplified split-bolus CTU technique for a routine CT list: Page 2 of 18

3 - 750ml oral water 30mins prior to scanning (to maximise ureteric distention) - Low dose, pre-contrast CT of renal tract (for calcification) - 100ml (300mgIodine/ml) iv contrast by hand - At 12mins, further 50ml iv contrast (3ml/s pump injected) - After 120s, Supine CT abdomen and pelvis Hence obtaining combined NEPHROGRAPHIC and EXCRETORY phases (fig 1). Images for this section: Fig. 1: Axial and coronal CTU images show homogenous enhancement of the renal cortex (nephrographic phase; asterisks) and opacified urine in the collecting system Page 3 of 18

4 (excretion phase; arrows). A bulky left upper pole TCC (T) and the distended, opacified bladder (B) are labelled Page 4 of 18

5 Imaging findings OR Procedure details The Gwent Healthcare NHS Trust radiology information system was interrogated for all patients investigated with CTU for haematuria over a 12 month period from October These were performed at one of two hospitals in South-East Wales. Results Audit period: 1st Oct 2007 for 12 months. 339 CTU scans performed (338 patients - 1 patient was recalled due to an initial poor quality scan): Male 223 (66%), female 115 (34%) Mean age: 62.7yr (range 25-88yr) Macroscopic haematuria 240 (71%), microscopic 73 (22%), non-specified 25 (7%) Age <40yr: 15 (4%) - no tumours, 1 renal tract stone Renal tract pathology was found in 80 (23.7%) patients, with a radiological diagnosis of renal tract tumour in 32 (9.5%) patients and stone disease in 48 (14.2%) patients (see fig. 1). Fig. 2 shows an unusual case of a calculus within a ureterocele. Where histological correlation was available (23 patients), all the radiological diagnoses of malignancy were confirmed apart from a single case of bladder wall thickening found to be due to inflammation (see figs. 3,4). Examples of histologically proven upper and lower urinary tract TCCs are shown (figs. 5-8) and two cases that proved diagnostic challenges (figs. 9,10) Extra-renal tract pathology included a collection associated with an aortic graft (fig. 11), endometrial carcinoma (fig. 12), liver haemangioma and diverticulitis. Images for this section: Page 5 of 18

6 Fig. 1: Pie chart showing the diagnoses of haematuria made on CTU Page 6 of 18

7 Fig. 2: Axial CTU image shows a dependent calculus (short arrow) in a slighly less dense opacified right ureterocele (long arrow). The calculus was more easily visualised on the pre-contrast image. Fig. 3: Table of all radiologically diagnosed renal tract tumours and histological correlation, where available. Page 7 of 18

8 Fig. 4: Table of characteristics of all histology confirmed renal tract tumours. Fig. 5: Axial and coronal CTU images show homogenous enhancement of the renal cortex (nephrographic phase; asterisks) and opacified urine in the collecting system (excretion phase; arrows). A bulky left upper pole TCC (T) and the distended, opacified bladder (B) are labelled Page 8 of 18

9 Fig. 6: Coronal CTU reformat shows a non-opacified (completely obstructed) left collecting system and extra-renal pelvis (P) with a soft tissue mass at the PUJ (arrow) histologically proven to be a TCC. IVU would have been unhelpful in this case. Page 9 of 18

10 Fig. 7: Coronal CT reformat showing a left mid-ureteric TCC (arrow) clearly outlined with contrast. Opacified bladder is labelled (B). Page 10 of 18

11 Fig. 8: Axial CTU image of biopsy proven TCC of the left bladder wall (long arrows) with peri-vesical fat stranding (short arrows) suggesting T3 disease. Layering of contrast is seen in the bladder. Page 11 of 18

12 Fig. 9: Axial and coronal CTU images show a small filling defect in a left lower pole calyx (arrows) which was unchanged on follow-up imaging and thought to be a prominent papilla. Page 12 of 18

13 Fig. 10: Axial CTU image shows generalised thickening (arrows) of the walls of a poorly distended bladder. Catheter balloon is labelled (*). It is impossible to confidently diagnose or exclude a lower tract TCC. Page 13 of 18

14 Fig. 11: Axial and coronal CTU images show a collection associated with an aortic graft (C) which involves and displaces the opacified left ureter (arrow). Page 14 of 18

15 Fig. 12: Axial CTU and sagittal T2W MR images show a biopsy proven endometrial carcinoma (arrow) with surrounding endometrial fluid. Page 15 of 18

16 Conclusion We have successfully replaced the IVU with a simplified CTU protocol of non-contrast plus combined nephrographic and excretory contrasted phases. These are performed on general CT lists and reported by most consultants in the hospital Trust. We use CTU as a second line investigation for high-risk haematuria which explains differences in the mix of renal tract malignancy in our audit (see fig.1) compared to that of an unselected group of haematuria patients [2,3]. Most superficial bladder TCCs detected on cystoscopy are treated prior to a CTU and hence our relatively high proportion of upper tract TCCs. A cause of haeamaturia is found in approximately one quarter of all scans which compares favourably with investigations for other symptoms and helps to justify a relatively high-radiation dose investigation. An average dose length product for our CTUs of mgycm was higher than expected and we are looking at ways of limiting radiation dose. These may include not performing additional prone scans in selected cases to try to improve distention of the ureters, removing the non-contrasted scan from the protocol and limiting the use of CTU in patients under 40 years old. Images for this section: Page 16 of 18

17 Fig. 1: Pie chart showing the diagnoses of haematuria made on CTU Page 17 of 18

18 Personal Information L. D. Wheeler, R. Clements, M. Robinson. Department of Radiology, Royal Gwent Hospital, Cardiff Road, Newport. NP20 2UB. Wales contact: References 1. Van Der Molan AJ, et al. CT Urography: definition, indications and techniques. A guidance for clinical practice. Eur Radiol (2008) 18: Edwards TJ et al. A prospective analysis of the diagnostic yield resulting from the attendance of 4020 patients at a protocol-driven haematuria clinic. BJUI 2006; 97(2): Vikram R, Sandler CM, Ng CS. Imaging and staging of TCC: Part 2, Upper Urinary Tract. AJR 2009; 192: Page 18 of 18

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