CT urography: Saline infusion vs furosemide

CT urography: Saline infusion vs furosemide Poster No.: C-1296 Congress: ECR 2010 Type: Scientific Exhibit Topic: Genitourinary Authors: C. M. Rodríguez Paz, M. Otero García, P. Rodríguez Fernández, A. Tilve Gómez, J. Sáez Martín; Vigo/ES Keywords: CTU, Furosemide, Saline DOI: 10.1594/ecr2010/C-1296 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. www.myesr.org Page 1 of 40

Purpose The aim of this study was to prospectively compare the effectiveness of low dose furosemide versus intravenous saline in improving the distension and opacification of the pelvicalycial system and ureters with different delay time for the excretory phase. Fig.: Purpose - Objectives References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Images for this section: Page 2 of 40

Fig. 1: Purpose - Objectives Page 3 of 40

Methods and Materials Subjects From September 2008 to June 2009, 83 outpatients referred for CTU examination were randomized in one of two groups: Group A: CTU protocol with intravenous saline administration (n: 43) or Group B: CTU protocol with low dose Furosemide (n: 40). Finally we have studied 166 collecting systems and ureters. We have randomized the days that CTU are performed in our center, so that each day we only use one a protocol. There ve been included all patients that their doctor has requested a CTU except in cases where there was a contraindication. We have considered contraindication for this study: high serum creatinine and creatinine clearance levels, acute obstructive uropathy, any cause of congestive cardiac failure, diuretic or contrast material allergy, and a history of dehydration were excluded. No patient was excluded or lost follow-up. Page 4 of 40

Fig.: Subjets, inclusion and exclusion criteria References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN The main indications for CTU are detailed in CTU indications table on page 14. Diagnostic studies of macroscopic hematuria and recurrent urinary tract infections are the most demanded test. Controls of transitional cell carcinoma, benign surgery and stones are another important indication. Fig.: CTU indications graphic References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN All patients were given 500 ml of drinking water during 30 min before the examination and were asked to empty their bladder before scanning. CTU adquisition on page 15 and image reconstruction Page 5 of 40

The MDTCU was performed on a 16 detector multislice CT Somatom Sensation 16 using a two-phase protocol (nephrographic and excretory phases). Single bolus of non-ionic contrast material, 100 ml of 320 mgi/ml was injected intravenously at a flow rate of 3 ml/sec. The Group A: The contrast material injection was followed immediately by 250 ml of normal saline injected at 2 ml/s. The Group B: 1-3 min before the contrast material injection, 10 mg of Furosemide (Seguril ) was injected. The nephrographic phase was obtained in both groups at 100 s after initiation of the intravenous injection. The excretory phases were obtained in Group A (saline) at 600 s delay time from start of injection and in group B (low dose Furosemide) at 300 s delay time. Page 6 of 40

Fig.: CTU adquisition table References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Image analysis on page 16 Fig.: Image analysis References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN For this study, only the excretory phase was used. On the workstation, the data were post-processed by each radiologist using coronal and curved multiplanar reformated Images MPR, MIP and VR. Page 7 of 40

All images were reviewed by three independent and specialized radiologists in the genitourinary area. Two radiologists were blinded to the protocol used for each study and they applied the qualitative score of opacification of the excretory system. The third radiologist, knows which protocol was used for each study, he performed the same qualitative analysis and a quantitative analysis, using data from opacification of the excretory system. Each collecting system and ureter evaluated on the excretory phase was divided into 6 segments on page 17: the upper and lower intrarenal collecting systems, renal pelvis, upper (above the iliac crest), medium (to the level of the sciatic notch) and lower (distal) ureter (below the sciatic notch). This resulted in 12 anatomic segments per patient. Page 8 of 40

Fig.: Excretory system segmentation: the upper (SC) and lower (IC) intrarenal collecting systems, renal pelvis (Pelvis), upper ureter (SU - above the iliac crest), medium (MU - to the level of the sciatic notch) and lower ureter (IU below the sciatic notch). References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN The renal pelvis was only valorated in the qualitative analysis regarding its opacification. No quantitative measures were recorded for renal pelvis or collecting system because there is an enormous variability of its appearance (e.g: extrarenal pelvis) among otherwise normal and asymptomatic patients. Qualitative analysis: on page 18 For the qualitative opacification analysis we reviewed axial and 2-3D images. A four score-point scale has been used (0: unopacified segment, 1: less than 50%, 2: more than 50%, 3: 100% opacified). For each segment, the reviewers assigned an opacification score based on the percentage of opacification determined by the length of the segment opacified. Quantiative analysis: on page 18 Only axial images were used and quantitative opacification has been measured with a ROI set (manual) on page 19 to the size of the ureter (in Hounsfield Units (HU). For ureteral distension we manually measured with electronic calipers the maximum axial diameter in millimeters. Page 9 of 40

Fig.: Qualitative and quantitative analysis References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Page 10 of 40

Fig.: Manual ROI to measure HU in ureter References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Statistical analysis on page 20 Page 11 of 40

Fig.: Statistical analysis References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Demographic data of both groups: age, sex and distribution in the study groups were studied with variance analysis and Fisher's test. To perform the qualitative analysis on page 21 we have taken together the data from the two ureters of each patient (166 ureters). Due to the few values other than 3 (less than 100% opacification) we have combined this three values creating a new variable (100 % and less than 100% opacification). With this values we have made a 2x2 contingency table and applied Fisher's exact test to calculate p. For quantitative variables results, statistical differences were calculated using t-student test. Interobserver concordance was calculated by kappa index. A p value less than 0.05 was considered to be statistically significant. Page 12 of 40

Fig.: Qualitative statistical analisys References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN All statistics data were performed with SPSS (Version 17.0, SPSS Inc., Chicago IL, USA). Images for this section: Page 13 of 40

Fig. 1: Subjets, inclusion and exclusion criteria Page 14 of 40

Fig. 2: CTU indications graphic Page 15 of 40

Fig. 3: CTU adquisition table Page 16 of 40

Fig. 4: Image analysis Page 17 of 40

Fig. 5: Excretory system segmentation: the upper (SC) and lower (IC) intrarenal collecting systems, renal pelvis (Pelvis), upper ureter (SU - above the iliac crest), medium (MU - to the level of the sciatic notch) and lower ureter (IU below the sciatic notch). Page 18 of 40

Fig. 6: Qualitative and quantitative analysis Page 19 of 40

Fig. 7: Manual ROI to measure HU in ureter Page 20 of 40

Fig. 8: Statistical analysis Page 21 of 40

Fig. 9: Qualitative statistical analisys Page 22 of 40

Results Demographic analysis: on page 28 83 patients (44 men and 39 women) have been included in the study, 43 of whom were assigned to intravenous saline infusion protocol (Group A) and 40 patients were assigned to furosemide protocol (Group B). Finally we studied 86 excretory systems in Group A and 80 in the group B. Mean age of all patients was 60.5 years (SD: +15.75 years, range 26-88 years). All patients were distributed without significant differences between both study protocols. Fig.: Demographic results graphics References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Page 23 of 40

Qualitative analysis: With intravenous saline, 31 (36%) excretory systems were full opacified and 55 (64%) achieved an incomplete opacification. Furosemide improved the opacification provided that 46 (57.5%) excretory system were completely opacified and 34 (42.5%) did not. In spite of the fact that in the group A, the excretory phase was realized after 10 minutes (600 s) and in those of the group B at 5 minutes (300 s), furosemide improved the full opacification in almost all the excretory system (p: 0.004), unless in the upper ureteral segment. The lower ureter was also better opacified with furosemide (p: 0.001). The right lower ureter achieved the 74,4% and the left lower ureter the 71,8%. With intravenous saline the percentages were 52,4% and 46,6% respectively. Quantitative analysis: on page 30 Atenuation values, measured in Housnfield units, were higher with the saline infusion protocol (p< 0.05). With furosemide protocol attenuation values were lower but more homogeneus. The urine is less dense after furosemide injection and provides an homogeneous density in the whole excretory system (from calyx to lower ureter). The mean density varies between 300-350 HU. After intravenous saline injection, the density is variable: between 450-700 HU, reaching the highest peaks in pelvis and calyx. Despite the peaks of urine density, we did not observe streak artefacts and all calyx and pelvis were diagnostic. Page 24 of 40

Fig.: Quantitative opacification table References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN The ureteral width on page 31 was manually measured on axial images with electronic calipers. No significative difference between saline and furosemide was found in the ureteral diameter (p> 0.05). The only ureteral segment where furosemide improves the distension, not significantly, was the lower right ureter. The lowest ureteral size was 3 mm. and the broader size was 12 mm., both in upper ureters. Mean ureteral size values are shown in the table. Page 25 of 40

Fig.: Ureteral distension graphic. References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Interobserver readers agreement on page 32 was high (k:0.71, 0.74,0.80), (P:0.001). Page 26 of 40

Fig.: Interobserver agreement References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Furosemide was safe and we did not have complications. Page 27 of 40

Fig.: CTU with intravenous saline (left) and furosemide (right). In the left image we can see an asymmetric renal parenchyma due to chronic changes in the left kidney, a lithiasis in the lowere calyx ( black arrow) and an hypertrophic right kidney. References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Images for this section: Page 28 of 40

Fig. 1: Demographic results graphics Page 29 of 40

Fig. 2: Qualitative opacification data table. Page 30 of 40

Fig. 3: Quantitative opacification table Page 31 of 40

Fig. 4: Ureteral distension graphic. Page 32 of 40

Fig. 5: Interobserver agreement Page 33 of 40

Fig. 6: CTU with intravenous saline (left) and furosemide (right). In the left image we can see an asymmetric renal parenchyma due to chronic changes in the left kidney, a lithiasis in the lowere calyx ( black arrow) and an hypertrophic right kidney. Page 34 of 40

Conclusion In our experience furosemide use for CTU improves the visualization of the collecting system compared to intravenous saline. Qualitative opacification of the excretory system in CTU is better with furosemide than with the saline infusion protocol in all segments of the urinary tract. In Hounsfield units (quantitative), opacification with the furosemide protocol is lower than with the saline infusion protocol, but provides a more uniform distribution and sufficient image quality for the diagnosis Fig.: Conclusions References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Page 35 of 40

Images for this section: Fig. 1: Conclusions Page 36 of 40

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12. Kawamoto S, Horton KM, Fishman EK (2006) Opacification of the collecting system and ureters on excretory-phase CT using oral water as contrast medium. AJR Am J Roentgenol, 186(1):136-140 13. Caoili EM, Cohan RH, Inampudi P, et al. (2005) MDCT Urography of Upper Tract Urothelial Neoplasms. Am. J. Roentgenol., 184(6):1873-1881 14. Sanyal R, Deshmukh A, Singh Sheorain V, Taori K (2007) CT urography: a comparison of strategies for upper urinary tract opacification. European Radiology, 17(5):1262-1266 Personal Information Dr. Carlos Manuel Rodríguez Paz Department of Radiology Complexo Hospitalario universitario de Vigo Pizarro 22, 36204 Pontevedra (Spain) e-mail: Carlos.manuel.rodriguez.paz@sergas.es Fig. References: C. M. Rodríguez Paz; Radiology, Complexo Hospitalario Universitario de Vigo, Vigo, SPAIN Images for this section: Page 38 of 40

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