Calculation of internal costs in a department of diagnostic radiology

Even though high technology accounts for less than 1% of health care costs in industrialized countries, radiology is often blamed for their escalation. In a squeezed health care economy it is important to know the real cost of diagnostic radiological procedures in order to set priorities and realistic budgets, and to bill (actually or fictively) referring departments, physician's patients, insurance companies etc., and to demonstrate real costs of radiology for politicians and clinicians. The so-called Radiology Points used in the Nordic countries are in our opinion not adequate as basis for "price tags", even if to some extent they do reflect work and expenses involved in an examination. The real costs of ultrasonography (US) and excretory urography (UG) of the upper urinary tract have been compared in a study being performed to determine whether US can replace UG as the first examination in upper urinary tract disease. The cost of US is 53% (high osmolar contrast media) or 27% (anionic contrast media) of UG. If US can replace UG as the first examination in upper urinary tract disease the cost savings will be dramatic, especially if low osmolar or anionic contrast media are routinely used.     

Imaging and the first urinary infection in children. Respective role of each test during the initial evaluation apropos of 122 cases

122 pediatric patients with a first urinary tract infection underwent renal ultrasonography (US) and voiding cystourethrography (VCUG) to evaluate the usefulness of this association. The US was always the first examination undertaken, its sensitivity seems to be very good in detecting renal abnormalities. The major finding on the VCUG was the vesico-ureteral reflux: 25% of cases. When the sonogram and the VCUG are normal, 60% of cases, excretory urography is not considered necessary.     

Ultrasound versus excretory urography in evaluating acute flank pain

To determine the role of ultrasound (US) in patients with acute flank pain and suspected acute urinary tract obstruction, a prospective study was performed on 20 patients comparing US with emergency excretory urography. US was not as sensitive as excretory urography for diagnosing hydronephrosis, for detecting ureteral or renal calcification, or for diagnosing forniceal rupture. Although US is an effective screening modality for hydronephrosis in patients with chronic renal obstruction, it is not useful for evaluating patients with acute flank pain in whom acute obstruction may be present. In this group of patients, excretory urography remains the examination of choice.     

Ultrasonography plus direct radiography of the abdomen in the diagnosis of renal colic: still a valid approach?]

PURPOSE: The authors analyze whether the imaging approach consisting of ultrasonography and plain film in patients with renal colic is still of value when urography is replaced by unenhanced helical CT (UHCT) in unsolved cases. MATERIAL AND METHODS: Eight hundred and three consecutive patients were investigated with US following hydration and KUB, 164 of whom (20.4%) subsequently underwent UHCT (42 with the aim of mapping the excretory pathway and 122 (15.2%) because US and KUB were not considered as fully diagnostic). RESULTS: The 42 patients with detectable ureteral stone (plus possible hydronephrosis) on KUB + US and subsequently examined by UHCT to plan interventional treatment all had a positive UHCT examination. In 62 patients the diagnosis following KUB + US was uncertain (possible stone or possible hydronephrosis) and UHCT depicted the stone and/or the hydronephrosis in 34. In 60 patients the combination of KUB + US was negative but colic recurred and UHCT was positive in 17 patients. DISCUSSION: The comparison of the present results with a previous study in which KUB and US were followed by IVU in unsolved cases underscores the value of the first approach with KUB and US. The need for further diagnostic investigations when KUB + US are either not conclusive or negative and colic recurs is also confirmed. On the basis of our present data and in agreement with the literature IVU can be safely replaced by UHCT. CONCLUSIONS: It is authors' opinion that in settings where KUB, US and UHCT are available throughout the 24 hr the approach consisting of KUB plus US and UHCT in unsolved cases can be preferred in view of its on lower cost and above all lower X-ray dose to patients as compared to UHCT as the sole investigation.     

Voiding cystourethrography: the initial radiologic study in children with urinary tract infection

The order in which children with urinary tract infection should undergo voiding cystourethrography (VCUG), excretory urography (EU), and/or renal ultrasonography (US) is not standardized. To determine a logical sequence of study, we performed VCUG and then either US or EU on 389 consecutive children with urinary tract infections. Thirty-seven percent (133/358) of the children were found to have reflux; of these, 22.5% (30/133) had an abnormal excretory urogram. No correlation was found between either the age of the child and the degree of reflux or the age of the child and the percentage of children with abnormal excretory urograms. Since normal EU or US results do not exclude significant reflux, VCUG is recommended as the preferred initial screening examination in children with urinary tract infection.     

Urinary tract infection in infants and children evaluated by ultrasound

Fifty-nine pediatric patients with urinary tract infection (UTI) underwent renal ultrasonography, excretory urography, and voiding cystourethrography. The imaging procedures were analyzed retrospectively to determine their relative effectiveness in detecting abnormalities that might predispose the patient to UTI. Voiding cystourethrography provided valuable information, particularly the presence or absence of vesicoureteral reflux, that could not be obtained from the other procedures. Excretory urography was less specific than ultrasonography in the majority of patients, with the exception of those who had renal scarring. The authors recommended ultrasonography as the initial imaging procedure in the evaluation of children with UTI. When the sonogram is normal, excretory urography is not considered necessary, but voiding cystourethrography is thought to be essential. If sonography is abnormal, excretory urography and/or other follow-up studies are indicated.     

Ultrasonography in the diagnosis of hydronephrosis in patients with normal renal function

In order to define the sensitivity and specificity of ultrasonography (US) in the diagnosis of hydronephrosis, 125 patients with normal renal function were examined after urography using high-resolution real-time scanning. The overall diagnostic accuracy of US in detecting hydronephrosis was 85.2%, with a specificity of 84.4% and a sensitivity of 89.9%. It is concluded that US may be considered the screening test of choice for the diagnosis of hydronephrosis. However, urography is still required for the evaluation of renal function, site, and nature of the obstruction when US shows a dilated collecting system and in the patient with a normal US but renal colic.     

The changing scene of radiology: value of urography as initial examination in infectious and hypertensive disease, hematuria and malignant disease

Four to 20% positive findings were found in a review of 1913 excretory urographics. Possibly relevant findings were 20% in patients referred for infectious disease, 10% in hypertensive disease, 6% in hematuria and 4% in neoplasms. Urography influenced treatment mainly in the 2 groups with few positive findings. The costs for positive findings may be acceptable in patients with hematuria or suspicion of neoplasms, but are too high in the other groups. Until ultrasonography can replace intravenous urography as the first screening method in upper urinary tract disease, the patient selection for urography in infectious and hypertensive disease should be improved.     

The role of ultrasonography in the diagnosis of tumours of the renal pelvis

The authors have evaluated 22 patients with renal pelvis tumour (RPT) by means of excretory urography and ultrasonography. Six patients also underwent arteriography. The value of the three investigations in the diagnosis of the lesion, the nature, the pyelic origin and the extension are presented. It is concluded that urography remains the method of choice for the evaluation of RPT while ultrasonography may be considered complementary to urography in cases of non-functioning kidney, when the urographic filling device defect is uncertain and in the differentiation between the pyelic or parenchymal origin of the tumour.     

Ultrasonic diagnosis of ureteral calculi in patients with acute flank pain

The diagnostic value of ultrasonography (US) and intravenous urography has been compared in a prospective study comprising 123 consecutive patients with severe acute flank pain of less than 72 hours' duration. Ultrasonography was performed transabdominally with a 5 MHz sector real-time transducer. Ureteral calculi were considered the final diagnoses in 46 patients, of which 35 with and 11 without accompanying hydronephrosis. Ureteral calculi were correctly diagnosed by US in 17 patients (sensitivity 37%). If hydronephrosis with or without calculus is included as a positive sign of ureteral calculus, a correct diagnosis was suggested by US in 34 patients (sensitivity 74%). We consider US to be a valuable method in patients with previous contrast media reactions, but recommend urography as the standard imaging method when renal colic is clinically suspected.     

先天性输尿管狭窄的影像学诊断(附31例分析)

目的：探讨超声检查(US)、静脉尿路造影(IVU)、CT和磁共振尿路成像(MRU)对先天性输尿管狭窄的诊断价值。方法：回顾性分析经手术病理证实的31例先天性输尿管狭窄的US、IVU、CT资料，其中4例行MRU检查。结果：US、IVU、CT和MRU对先天性输尿管狭窄定位诊断的总符合率分别为67．74％、87．10％、96．77％、100％，对病因定性诊断的总符合率分别为48．39％、77．42％、93．55％、50％。结论：CT、IVU对病因的定性诊断符合率较高，但四种影像学检查方法又各具优势和特点，应根据具体情况和临床需要进行选择，两种或两种以上影像学检查方法的联合应用，更能提高先天性输尿管狭窄的诊断符合率。     

The coexistence of ureteropelvic junction obstruction and reflux

Since ureteropelvic junction obstruction is the most common upper urinary tract problem in children, and vesicoureteral reflux the most common lower tract problem, it is not surprising that these entities sometimes coexist in the same child. Over a 10 year period this uncommon phenomenon has been noted 21 times (in about 2,800 children with reflux and 200 children with ureteropelvic junction obstruction). Significant ureteropelvic junction obstruction in association with mild reflux can mimic severe reflux, but the operation needed is not reimplantation but pyeloplasty. Conversely, when significant ureteropelvic junction obstruction coexists with significant reflux, both operations may be necessary, but the order in which they are done (pyeloplasty first) seems to be crucial. Voiding cystography with appropriate postvoid drainage films, excretory urography, often with a catheter draining the bladder to prevent reflux, and provocative diuretic excretory urography and/or renography can determine that ureteropelvic junction obstruction does coexist and quantitate the severity of each problem.     

超声检查和X线尿路造影对输尿管狭窄诊断的临床研究（附98例分析）

目的：评价超声检查和X线尿路造影在输尿管狭窄中的诊断价值,帮助临床医生合理地选择检查方法。方法：本组98例输尿管狭窄的患者均作了超声及静脉尿路造影检查,36例作了逆行尿路造影。结果：超声、静脉尿路造影、逆行尿路造影对输尿管狭窄定位诊断的总符合率分别为66．3％、86．7％和94．4％。不同检查方法对不同部位诊断的符合率不同,对肾盂输尿管移行区,输尿管末端,肾盂输尿管移行区－输尿管末端之间诊断符合率超声分别为83．3％、75％和33．3％,静脉尿路造影分别为79．2％、95％和93．3％,逆行尿路造影分别为95％、75％和100％。输尿管狭窄病因的诊断符合率超声为42．9％,静脉尿路造影为78．6％,逆行尿路造影94．4％。结论：尿路造影是诊断输尿管狭窄的可靠方法,超声因经济、简便可作为一种首选的检查手段。     

Diagnostic value of diuretic-enhanced excretory MR urography in patients with obstructive uropathy

PURPOSE: Ultrasonography and conventional intravenous urography are most common methods in diagnosis of obstructive uropathies. The disadvantage of ultrasonography is inability of visualizing middle and lower one thirds of ureter, while intravenous urography is using radiation, also functionally extra loading effect on kidneys. In this study, the diagnostic value of MR urography on obstructive uropathy were investigated. MATERIALS AND METHODS: Forty five patients who were suffered from obstructive uropathy examined by ultrasonography, intravenous urography and diuretic-enhanced excretory MR urography by using MR-contrast-agent. RESULTS: MR urography established accuracy rate of 92.8% for stone diseases which formed the largest group in this study, however, in other causes of obstructive uropathy, MR urography provide 100% correct diagnosis. CONCLUSION: MR urography provide high quality images for diagnosing and determining causes of urinary obstruction defining position and severity of dilatations as well as showing localization of the pathology. We think that MR urography should be a primary investigation in patients with obstructive uropathy who have contrast agent and X-ray contrindication.     

Effectiveness of MR Urography in the Evaluation of Kidney which Failed to Opacify during Excretory Urography: Comparison with Ultrasonography

Objective

The purpose of this study was to compare the effectiveness of MR urography (MRU) with that of ultrasonography (US) in the evaluation of urinary tract when this failed to opacify during excretory urography (EXU).

Materials and Methods

Twelve urinary tracts in 11 patients were studied. In each case, during EXU, the urinary system failed to opacify within one hour of the injection of contrast media, and US revealed dilatation of the pelvocalyceal system. Patients underwent MRU, using a HASTE sequence with the breath-hold technique; multi-slice acquisition was then performed, and the images were reconstructed using maximal intensity projection. Each set of images was evaluated by three radiologists to determine the presence, level, and cause of urinary tract obstruction.

Results

Obstruction was present in all twelve cases, and in all of these, MRU accurately demonstrated its level. In this respect, however, US was successful in only ten. The cause of obstruction was determined by MRU in eight cases, but by US in only six. In all of these six, MRU also successfully demonstrated the cause.

Conclusion

MRU is an effective modality for evaluation of the urinary tract when this fails to opacify during EXU, and appears to be superior to US in demonstrating the level and cause of obstruction.     

排泄性磁共振尿路造影对小儿尿路畸形的评估

目的:探讨应用利尿剂的排泄性磁共振尿路造影(EMRU)诊断小儿尿路先天畸形的应用价值.材料和方法:对24例已知或高度怀疑尿路先天畸形的儿童进行磁共振水成像尿路造影及增强后排泄性尿路造影(MRU),患者都使用了利尿剂.由2位经验丰富医师在不知病史的情况下分别对两种MRU成像方法的图像进行质量评估并做出对比分析.结果:60.4%的水成像与85.4%排泄性MRU图像质量达到了诊断要求;58.3%排泄性MRU与相应的成像MRU相比,其图像质量和观察效果得到了提高或改善;其中20例(20/24,83%)患者做出定位定性诊断,2例(2/24,8.3%)排除了相关异常.结论:利尿剂排泄性磁共振尿路造影(EMRU)能比较准确的显示泌尿路先天畸形,可以替代传统方法用于大部分怀疑有先天畸形的患儿.     

Present-day imaging of patients with renal colic

In the past decade alternatives to urography have been proposed for the study of patients with renal colic. In 1992 it was suggested to replace urography with KUB and ultrasonography. In 1993 the combination of KUB and ultrasonography followed by urography in unresolved cases was proposed and, in 1995, it was suggested to replace urography with unenhanced helical CT (UHCT). This article illustrates the contribution of UHCT to the study of patients with renal colic and analyses advantages and shortcomings of the technique compared with other diagnostic approaches. Diagnostics of the patient with renal colic is based on the detection of direct and indirect signs which allow identification of not only the calculus, with a sensitivity of 94–100 % and accuracy of 93–98 % according different authors, but also other signs that can serve to guide patient management and evaluate long-term prognosis. Unenhanced helical CT has the capability to detect extraurinary abnormalities which present with flank pain and mimic renal colic. The examination technique affects the quality of the images and therefore diagnostic accuracy as well as the dose to the patient. With regard to setting parameters, the choice of thickness and table feed should be guided by numerous factors. Multiplanar reconstruction is indicated in the study of the entire ureter course to identify the exact site of the calcification for the urologist to perform an evaluation similar to that obtained by urography. Many authors consider UHCT to be a valuable tool for suggesting the best therapeutic approach. Among these there are also urologists. The evaluation is based on the stone detection, its size and level in the urinary tract. Cost analysis shows that the cost of UHCT is equal to or inferior to the cost of urography. With regard to the dose, different data are reported in the literature. A high pitch (more than 1.5) and a thin collimation (3-mm thickness) are good compromise between quality and dose which can be compared to the dose of normal urography. What is to be done if helical CT is not available? If helical CT is not available, plain film plus ultrasonography should be considered. This approach does not solve all the cases; in unresolved cases urography is indicated. It should also be noted that US has a good sensitivity in detecting other conditions such as biliary lithiasis, acute pancreatitis, acute appendicitis and abdomino-pelvic masses which are responsible for pain that mimics renal colic. In conclusion, IVU should not have any more the priority in investigating the patients with renal colic. Helical CT should be the first choice in imaging a patient with renal colic. If this technique is not available, plain film and ultrasonography should be considered adding urography in unresolved cases.     

Urinary tract infections in children: renal ultrasound evaluation

Ultrasound may replace urography in screening pediatric patients with uncomplicated urinary tract infections but without vesicoureteral reflux. A child undergoing a first radiographic evaluation for urinary tract infection is initially examined by voiding cystourethrography. If reflux is present, urography is performed. If no reflux is present, the kidneys are evaluated by real-time ultrasound; urography may also be performed if the ultrasound examination is abnormal, equivocal, or inadequate. A total of 192 patients was evaluated with this protocol; 146 (76%) had no reflux and therefore were examined with ultrasound. One patient was found to have hydronephrosis and underwent surgical correction. This group of patients was compared with a similar group of 223 patients without reflux who were evaluated by urography prior to the institution of the ultrasound protocol; there was no significant difference between the two groups in upper urinary tract findings that influenced patient management.     

CT of trauma to the abnormal kidney

Traumatic injuries to already abnormal kidneys are difficult to assess by excretory urography and clinical evaluation. Bleeding and urinary extravasation may accompany minor trauma; conversely, underlying tumors, perirenal hemorrhage, and extravasation may be missed on urography. Computed tomography (CT) was performed in eight cases including three neoplasms, one adult polycystic disease, one simple renal cyst, two hydronephrotic kidneys, and one horseshoe kidney. CT provided specific and clinically useful information in each case that was not apparent on excretory urography.     

Sonography as a substitute for excretory urography in children with urinary tract infection

The possibility was explored of substituting renal sonography for excretory urography in children with urinary tract infection. Seventy-one patients were studied prospectively with voiding cystourethrography, sonography, and excretory urography; each examination was reviewed independently and without knowledge of the results of the others. Compared with urography the sensitivity and specificity of sonography was 100% and 51%, respectively, provided sonograms were of good technical quality. In a few instances, however, focal renal parenchymal scars were clearly seen only on urography. The findings suggest that in the absence of vesicoureteral reflux children with urinary tract infection should be studied with sonography. No further study is needed if a good-quality sonogram is within normal limits. In the presence of vesicoureteral reflux, however, or a suspicious or abnormal sonogram, excretory urography appears to be still necessary, at least at the present level of knowledge and technical expertise.