Multiphasic helical computerized tomography for the assessment of microscopic hematuria: a prospective study

PURPOSE: We evaluated multiphasic helical computed tomography for the detection and characterization of lesions responsible for hematuria not diagnosed on prior urological surveillance studies. MATERIALS AND METHODS: A total of 393 men and 207 women with recurrent microscopic hematuria but negative urological surveillance studies were examined at 4 participating institutions by multiphasic helical computerized tomography, consisting of pre-enhancement, arterial corticomedullary, parenchymal and excretory phase sequences generating 2 to 5 mm slices through the kidney and lower pelvis. RESULTS: The cause of microscopic hematuria was established in 256 of 600 patients with prior negative urological surveillance examinations with 0.91 sensitivity and 0.94 specificity. The diagnosis was correct in all subsequently proven cases of calculous and renal vascular disease. A total of 67 of 70 inflammatory kidney lesions, 24 of 25 renal neoplasms, 15 of 16 bladder neoplasms, 27 of 35 inflammatory bladder conditions and 21 of 23 ureteral lesions were also correctly diagnosed. The diagnosis of renal medullary and papillary necrosis, and neoplastic lesions of the kidney and bladder allowed the early institution of medical therapy or appropriate surgery. CONCLUSIONS: Multiphasic helical computerized tomography diagnosed lesions responsible for microhematuria in 42.6% of 600 patients with negative urological surveillance examinations. This relatively low cost and low co-morbidity examination is advocated for patients with negative urological surveillance examinations or even as a first examination.     

多层螺旋CT尿路造影对无痛性血尿的上尿路肿瘤的诊断价值

目的探讨多层螺旋CT尿路造影（MSCTU）在无痛性血尿的上尿路肿瘤患者中的诊断价值。方法采用前瞻性研究方法,收集本院2005年1月～2008年6月无痛性血尿患者,共512例,既往无尿路肿瘤病史,所有患者均行MSCTU、尿液及泌尿系统B超检查;用Logistic回归分析评价各变量在预测上尿路肿瘤的价值,各变量分别为MSCTU、泌尿系B超、血尿、年龄和性别。结果512例患者中,23例为上尿路肿瘤,MSCTU检出上尿路肿瘤患者19例,其敏感性、特异性、阳性预测率和阴性预测率分别为82．61％、98．77％、75．95％和99．18％。有6例假阳性和4例假阴性。Logistic回归分析显示：异常MSCTU（发现上尿路新生物）对探测上尿路肿瘤具有显著统计学意义（P〈0．0001）。结论MSCTU在无痛性血尿患者中诊断上尿路肿瘤敏感,且具有高度特异性,可作为无痛性血尿患者首选影像学检查。     

Significance and diagnostic accuracy of renal calculi found by ultrasonography in patients with asymptomatic microscopic hematuria.

BACKGROUND: The purpose of the present study was to evaluate the clinical significance and the accuracy of the diagnosis of renal calculi incidentally found by ultrasonography (US). METHODS: A total of 906 subjects (639 men and 267 women) aged 18-78 years were referred for asymptomatic microscopic hematuria. Of these, 743 patients who underwent US were studied. RESULTS: Hyperechogenic spots in the central echo complex suggesting renal calculi were noted in 195 patients (21.5%). The occurrence of hyperechogenic spots was higher in patients with 20 or more urinary red blood cells per high-power field (chi(2) = 4.896, P = 0.0269) and in men than in women (chi(2) = 7.101, P = 0.0077), but it was lowest in patients who were 29 years old or younger. Of these 195 patients, who were followed up for 1-161 months (average: 33.5 months), 24 patients (12.3%) needed urological management. Extracorporeal shockwave lithotripsy was carried out in eight patients, transureteral lithotripsy was carried out in three patients, spontaneous passage occurred in 11 patients and medication for hyperuricemia was initiated in two patients (1%). Among the patients in whom hyperechogenic spots were found on the kidney by US but calculi were not visible on abdominal plain radiographs, 39 patients underwent computed tomography. Of them, 31 patients were confirmed to have renal calculi. CONCLUSION: The obtained results suggest that US is an effective and reliable means of detecting renal calculi in patients with asymptomatic microscopic hematuria, and in facilitating prompt urological intervention or predicting the natural course of renal calculi.     

Low dose unenhanced helical computerized tomography for the evaluation of acute flank pain

PURPOSE: Unenhanced helical computerized tomography (CT) has proved to be an excellent diagnostic tool for evaluating acute flank pain with reported 95% to 100% sensitivity, 92% to 100% specificity, 96% to 100% positive and 91% to 100% negative predictive values. The diagnostic value of a new low dose protocol was prospectively studied and compared with the results of conventional unenhanced helical CT in a previous series with an effective dose equivalent (HE) of 3.1 to 4.3 mSv. and in current literature with an estimated HE of 4.3 to 4.7 mSv. MATERIALS AND METHODS: In 109 patients 18 to 86 years old with acute flank pain we performed low dose unenhanced helical CT in addition to abdominal ultrasound and urinalysis with new CT parameters (120 kV. 70 mA., 5 mm. collimation, pitch 2 and incremental reconstruction each 5 mm.) that led to a more than 50% decrease in radiation exposure to 1.50 mSv. in females and 0.98 mSv. in males. Ureteral calculi were confirmed or excluded by retrograde ureteropyelography in 51 cases. In the other cases the diagnosis was verified by the clinical and ultrasound course, and/or stone asservation. RESULTS: In 80 of the 109 patients the flank pain was caused by a ureteral calculus. Low dose unenhanced helical CT precisely identified 77 ureteral calculi with 1 false-positive finding. Thus, the sensitivity and specificity of low dose unenhanced helical CT were 96% and 97% with a 99% positive and 90% negative predictive value. In 15 of 29 patients with CT findings negative for stone disease different causes of pain were established by low dose unenhanced helical CT. CONCLUSIONS: Even with the significantly decreased radiation exposure of the low dose protocol unenhanced helical CT is still an excellent and rapid diagnostic tool for evaluating acute flank pain with lower radiation exposure than excretory urography (HE 1.3 to 2.3 mSv.) at our departments. Only in obese patients with a body mass index of greater than 31 kg./m.2 is conventional unenhanced helical CT with higher radiation exposure recommended to achieve adequate image quality.     

CT尿路成像和IVU检查诊断泌尿系统疾病的比较研究

目的 比较CT尿路成像(CTU)和IVU检查诊断泌尿系统疾病的准确率,探讨临床上CTU取代IVU的可能性.方法 CTU检查泌尿系统疾病患者165例.男111例,女54例.平均年龄42(18～71)岁.肾输尿管结石75例、肾盂输尿管连接处畸形30例、膀胱癌30例、肾盂旁囊肿和肾盂源性囊肿15例、双侧巨输尿管症9例、肾盂输尿管肿瘤6例.行IVU和CTU检查78例,行CTU、IVU和逆行肾盂输尿管造影(RP)检查12例,行CTU和RP检查24例,仅行CTU检查51例.结果 165例患者中,CTU和IVU检查诊断准确率分别为94.5%(156/165)、46.7%(42/90),二者比较差异有统计学意义(P＜0.01).二者诊断上尿路结石准确率分别为100.0%(75/75)、78.6%(33/42)(P＜0.05);CTU诊断肾盂输尿管连接部畸形准确率为90.0%(27/30),IVU检查15例仅能显示肾盂积水;CTU诊断膀胱癌准确率为100.0%(30/30),IVU检查12例,发现膀胱内充盈缺损9例(75%)(P>0.05)CTU诊断肾盂旁囊肿和肾盂源性囊肿准确率为80.0%(12/15),IVU检查10例无法显示囊肿范围与大小;CTU诊断双侧巨输尿管症准确率为100.0%(9/9),IVU检查6例仅发现患侧肾脏不显影或肾盂积水;CTU诊断输尿管恶性肿瘤准确率为100%(6/6),IVU检查5例仅发现患侧肾脏不显影或肾盂积水.CTU和IVU对上尿路梗阻性病变者患侧和(或)梗阻远端显示率分别为79.4%(81/102)、25.0%(15/60),二者比较差异有统计学意义(P＜0.01).CTU、IVU检查时间分别为(18.9±8.4)、(67.1±26.7)min,二者比较差异有统计学意义(P＜0.01).结论 CTU检查在诊断泌尿系统疾病准确率、了解病变周围组织情况以及对梗阻远端尿路显示率方面明显优于IVU检查,在大部分情况下可以取代IVU检查成为常规方法之一.     

尿路CT成像、静脉尿路造影对术前尿路疾病诊断的对比研究

目的评价尿路CT成像（CTU）、静脉尿路造影（IVU）在术前尿路疾病诊断中的作用。方法总结从2008年4～10月因尿路疾病住院手术的患者44例,其中44例经CTU检查、40例经过IVU检查,将检查结果与术后病理学结果比较,用X2分析检验其敏感性和准确性。结果CTU和IVU对于尿路病变的诊断结果与病理学结果的整体符合率分别为94．05％和24．36％,CTU诊断结果与病理学结果差异不明显（Kappa=3．30,P〉0．05）;IVU诊断结果与病理学结果具明显差异（Kappa=97．30,P〈0．01）。结论CTU对于尿路病变的诊断能力明显优于IVU,CTU的结果更接近病理学诊断。     

The role of computerized tomographic scanning in the evaluation of major pelvic fractures

Twenty-five patients with double vertical fractures of the pelvic ring had evaluations by both plain radiography and computed-tomography scanning of the pelvis. In eight of the twenty-five patients, the interpretation that was made from the plain radiographs, based on the classification of Pennal et al., changed when additional anatomical information was provided by the computed-tomography scan. We recommend that computed tomography be used for: (1) double vertical fracture-dislocations of the pelvic ring in which plain radiographs are inadequate to judge pelvic stability, (2) fractures of the pelvic ring with extension into the acetabulum, and (3) major injuries to the hemipelvis that are to be treated by open reduction and internal fixation. However, due to the increased cost and radiation exposure, routine computed-tomography scanning is not justified for all injuries to the pelvic ring.     

Differentiation of renal cell carcinoma subtypes by multislice computerized tomography

Purpose

We differentiated renal cell carcinoma subtypes using multislice computerized tomography (CT).

Materials and Methods

We reviewed the CT images of 87 patients with renal cell carcinoma. Three subtypes of renal cell carcinoma were noted, including clear cell in 37 cases, papillary in 26 and chromophobe in 24. Biphasic CT (unenhanced, corticomedullary and excretory phases) was done in all patients. We compared patient age and sex, tumor size, enhancement degree and pattern (homogeneous, heterogeneous and predominantly peripheral), the presence or absence of calcification or cystic degeneration (necrotic or hemorrhagic areas within the tumor) and tumor spreading patterns, including perinephric change, venous invasion and lymphadenopathy, in the 3 subtypes.

Results

The degree of enhancement was significantly different among the 3 subtypes in the corticomedullary and excretory phases (p <0.001). Cystic degeneration was more evident in the clear cell subtype than in the other subtypes regardless of tumor size (p <0.001). A hypervascular pattern (higher tumor enhancement after contrast material injection due to higher vascularity) was noted in 48.6% of clear cell subtype in comparison to 15.4% of papillary and 4.2% of chromophobe subtypes (p <0.001). The chromophobe subtype showed homogeneous enhancement in 75% of cases in comparison to 45% and 65% of clear cell and papillary subtypes (p >0.05). Calcification was evident in 21.6%, 23.1% and 25% of clear cell, papillary and chromophobe subtypes, respectively (p >0.05).

Conclusions

To differentiate the subtypes of renal cell carcinoma the degree of enhancement is the most valuable parameter. The presence or absence of cystic degeneration, vascularity and enhancement patterns can serve supplemental role in differentiating renal cell carcinoma subtypes.     

Three-dimensional navigator for retroperitoneal laparoscopic nephrectomy using multidetector row computerized tomography

PURPOSE: We evaluated the efficacy of a 3-dimensional (D) navigator for retroperitoneal laparoscopic nephrectomy. MATERIALS AND METHODS: A total of 21 patients with malignant localized renal (16) or ureteral (5) neoplasms underwent multi-detector row computerized tomography. The 3-D navigator was created using volume rendering technique. These findings were compared with videos obtained during laparoscopy. RESULTS: The 3-D navigator depicted all renal arteries (100% sensitivity) and 24 of the 25 renal veins (96% sensitivity). Hilar anatomy, including the tumor, major vessels and adrenal gland, and their relationships were visualized as in laparoscopic views. CONCLUSIONS: The 3-D navigator has a potentially important role in retroperitoneal laparoscopic nephrectomy. It is able to guide surgeons and aid in avoiding operative risks and possible complications.     

Multidetector CT urography: diagnostic role in the evaluation of patients with non-traumatic hematuria

Blood in the urine (hematuria) can originate from any site along the urinary tract and may be the only sign of renal or vesical malignancy. Therefore, literature recommends for the evaluation of any case of macroscopic or microscopic hematuria. Our aim was to define the diagnostic role of multidetector CT urography (MDCTu) in the evaluation of this symptom through the analysis of 181 consecutive patients from January 2003 to March 2006.     

Intravenous urography in evaluation of asymptomatic microscopic hematuria

BACKGROUND AND PURPOSE: In 2001, the American Urologic Association Best Practice Policy Panel recommended CT or intravenous urography (IVU) over ultrasonography as the initial imaging modality in patients with asymptomatic microhematuria. We here present results of a study initiated many years ago and completed prior to 2001 that provides information pertinent to the use of IVU as the initial imaging modality for such patients. PATIENTS AND METHODS: This study compared the results of IVU and ultrasonography in patients 40+ years of age who were referred to a single urology department for evaluation of microscopic hematuria between 1994 and 2000. There were 290 patients who agreed to participate by undergoing ultrasonography in addition to IVU; 247 completed both tests. There were 81 men and 166 women with a mean age of 56.4 years (range 40-86 years). Thirty patients (12%) were smokers. RESULTS: A renal lesion or mass suggestive of tumor was found in 8 patients (3.2%); 3 patients had this finding on the IVU examination and 5 on ultrasonography. None of the patients had such a lesion/mass on both examinations. Two patients with suspect lesions were ultimately found to have renal-cell carcinoma. Both of the patients with renal cancer had a suspect lesion on the ultrasound examination but not on the contemporaneous IVU. CONCLUSION: Intravenous urography may miss lesions/masses that lead to a diagnosis of upper-tract neoplasia.     

Ureteropyeloscopy in the diagnosis of patients with upper tract hematuria: An initial clinical study

BACKGROUND: To study the usefulness and safety of ureteropyeloscopy in the diagnosis of upper tract hematuria of unknown etiology by standard diagnostic methods. METHODS: Fifteen patients with upper tract hematuria of unknown etiology were the subjects of the present study. Prior to ureteropyeloscopy, they underwent standard diagnostic methods, including cystourethroscopy, excretory urography and computed tomography scan. The upper tract (ureter, renal pelvis and calyces) was inspected systematically with a flexible ureteropyeloscope under epidural anesthesia. A biopsy specimen was obtained when neoplasm of a suspicious lesion was seen. Bleeding and hemangiomatous lesions were fulgurated at the time of ureteropyeloscopy. RESULTS: Unilateral gross hematuria was seen in 12 patients. Imaging studies revealed a filling defect in four patients, ureteral stenosis in one patient and nutcracker phenomenon in one patient. Urine cytology was positive in three patients and suspicious in four patients. Results of ureteropyeloscopy were papillary tumor in three patients, whitish encrustation in one patient, redness of the renal pelvis in one patient, bleeding from the renal calyx in two patients, hemangiomatous lesion in one patient, ureteral stenosis in two patients and no abnormalities in five patients. Biopsies were performed in five patients. The pathology results were transitional cell carcinoma in four patients and no abnormality in one patient. Although a ureteral stent catheter was placed in one patient, no serious complications were encountered during or after the procedures. CONCLUSIONS: Ureteropyeloscopy was useful and relatively safe. This endoscopic examination can differentiate insignificant lesions from significant lesions by visual inspection of the lesions, in addition, pathological diagnosis by biopsy specimen can also be performed if deemed necessary. Ureteropyeloscopy is recommended in the diagnosis of upper tract hematuria of unknown etiology.