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Review of Techniques and Spectrum of the Ureteric Diseases Alexandria Journal of Medicine 54 (2018) 215–227 Contents lists available at ScienceDirect Alexandria Journal of Medicine journal homepage: http://www.elsevier.com/locate/ajme Original Article 64 MS-CTU: Review of techniques and spectrum of the ureteric diseases ⇑ Mahmoud Agha a,b, , Ahmed Fathi Eid c a Medical Research Institute, Alexandria University, Egypt b Almana General Hospital, Saudi Arabia c National Guard Hospital, Saudi Arabia article info abstract Article history: Objective: The study aims to clarify the sensitivity of the CTU, and if is it coast effective and time effective Received 15 March 2017 to be used as first and the one-stop shop imaging modality for the diagnosis of the different ureteric dis- Revised 4 June 2017 eases. Accepted 7 July 2017 Patients and methods: 400 patients with different urinary tract complaints (hematuria and/or renal colic) Available online 27 July 2017 did triphasic CTU examinations, for diagnosis of suspected obstructive or traumatic ureteric uropathy from January 2014 to October 2016. These patients were filtered from a larger number of patients – who were presented with urinary tract complaints by plain KUB X ray and US, which showed no explain- ing kidneys or urinary bladder pathology. Results: Ureteric duplication was detected in 5 (1.25%) patients, ectopic ureter in one patient (0.25%), UPJ stricture in 4 patients (1%), PUJ vascular impression in 2 patients (0.5%), ureteric calculus in 103 patients (25.75%), pyogenic ureteritis in 8 patients (2%), ureteritis cystica in one patient (0.25%) TCC in 3 patients (0.75%), PRPF in one patient (0.025%) and Trauma in one patient (0.025%). Conclusion: CTU is very sensitive tool of imaging and could be confidently considered the one-stop shop imaging tool for accurate diagnosis of the different ureteric lesions. Ó 2017 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 1. Introduction its lumen causing obstructive nephropathy, with resultant impaired renal function.1 The ureter is responsible for a considerable share of the urinary Anatomically, the ureter is a long thin duct which connects tract complaints, which are renal colic or pain, hematuria and urine from the kidney to the urinary bladder. Proximally, it arises impaired renal functions. Being retroperitoneal in position, of thin from the renal pelvis at the pelviureteric junction (PUJ) and ends caliber and long course; it is not always easy to diagnose ureteric distally into the urinary bladder at the vesicoureteric junction lesions, by conventional imaging methods like plain KUB, US or (VUJ) (Fig. 1). It leads a complete retroperitoneal course, having even IVP. So, it is not uncommon to miss some ureteric lesions at around 25 cm length, with less than 3 mm caliber width. Histolog- its early presentation, which will be definitely reflected upon the ically, it is lines with a layer of urothelium surrounded by a smooth outcome and prognosis of such disease. Also, its small caliber muscle layer that allows peristaltic contractions. So, it may be makes it possible for small ureteric lesions to completely obstruct normally not thoroughly opacified at CTU, as there may be some contracted non opacified segments at the time of the scan. How- ever, the absence of an obstructive cause and lack of proximal dilatation is the clue to consider it a physiological not pathological Abbreviations: AGH, Al-Mana General Hospital; CTU, computed tomography of phenomenon.2 the urinary tract; ESWL, extracorporeal shock wave lithotripsy; HIV, human After advent of the multislic CT scan, CTU had been increasingly immune-deficiency virus; HU, Hounsfield unit; IVU, intravenous urography; MSCT, multislic CT scan; PRPF, primary retroperitoneal fibrosis; PUJ, pelviureteric junc- requested during the last decade as the first urinary tract imaging tion; RTA, road traffic accidents; TCC, transitional cell carcinoma; UT, urinary tract; modality. With the continuously developing MSCT scan advances VUJ, vesicoureteric junction; VUR, vesicoureteric reflux. of CT urography, it is crucial for radiologists to be acquainted with Peer review under responsibility of Alexandria University Faculty of Medicine. the normal ureteral anatomy and the different ureteral patholo- ⇑ Corresponding author at: Medical Research Institute, Alexandria University, gies. These pathologic findings at CT urography include congenital Egypt. abnormalities, urolithiasis, inflammations, neoplastic lesions and E-mail address: [email protected] (M. Agha). http://dx.doi.org/10.1016/j.ajme.2017.07.002 2090-5068/Ó 2017 Alexandria University Faculty of Medicine. Production and hosting by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). 216 M. Agha, A.F. Eid / Alexandria Journal of Medicine 54 (2018) 215–227 A B C Fig. 1. (A) CRF, (B) SRF& (C) VR CTU showing: Left short segmental upper ureteric duplication (Arrows). Table 1 Results of CTU examinations. course abnormalities. As any imaging technique, it has sensitivity Diagnosis No. of patients Percentage (%) and specificity scores as well as some advances and some limita- tions. Also, many technical points are important to be issued in Ureteric duplication 5 1.25 3,4 Ectopic ureter 1 0.25 attempt to get perfect study with no technical errors. PUJ stricture 4 1 PUJ vascular impression 2 0.5 Ureteric calculus 103 25.75 2. Aim of the study Pyogenic ureteritis 8 2 Ureteritis cystica 1 0.25 TCC 3 0.75 The study aims to clarify the sensitivity of the CTU for diagnosis PRPF 1 0.025 of different ureteric diseases and if is it coast effective and time Trauma 1 0.025 effective to be used as first UT imaging modality for different clin- PUJ: pelviureteric junction, TCC: Transitional cell carcinoma, PRPF: Primary ically suspected ureteric diseases. retroperitoneal fibrosis. A B Fig. 2. (A and B) CTU CRF excretory phase in another patient with longer duplication ureteric segments (Arrows); medially displaced by large left renal Bosniak IVcystic neoplastic lesion (Chevron). M. Agha, A.F. Eid / Alexandria Journal of Medicine 54 (2018) 215–227 217 3. Patients and methods 3.2. Technique 3.1. Patients For CTU ureteric examination, there are worldwide three differ- ent used techniques; the triple phase, the dual split bolus phase 400 patients with different urinary tract complaints (hematuria and dual energy CT (DECT) one phase. In all techniques, adequate and/or renal colic) were referred to CT scan division of the radiol- patient’s hydration is crucial before IV contrast administration. In ogy department of Al-Mana General Hospital (AGH), with a sus- our hospital protocol, we used to give 250 ml IV saline 0.9%, just pected ureteric obstructive uropathy from January 2014 to before the start of the examination or 1000 ml oral distilled water October 2016. These patients were filtered from a larger number 4 h before the examination. This generous pre-contrast hydration of patients – who were presented with urinary tract complaints improves the diuresis, which helps to attain considerable or ade- by plain KUB X ray and US, which showed no explaining kidneys quate filling of the collecting system with contrast and protects or urinary bladder pathology. The study protocol was approved against the possible serious contrast induced nephropathy (CIN). by the scientific and ethics committee in Al-Mana General Hospital This CIN could be explained by the usual decrease in renal perfu- (AGH). A signed consent was obtained from all study candidates, sion which may last for 20 h following IV iodinated contrast including detailed description of the technique with the rare possi- administration, resulting in relative medullary hypoxemia and ble drawbacks. poor contrast elimination.5–7 A B C D E F Fig. 3. Non-contrast CTU (impaired renal function) (A, B and C CRF), (D SRF) and (E and F axial cuts) showing ectopic left ureter (Arrows) with distal end at the left seminal vesicle superolateral corner (Curved arrow) and left full length hydroureter and severe left renal hydronephrosis (Notched arrow). Compare with the normal right vesicoureteric junction (Chevron in E and F). 218 M. Agha, A.F. Eid / Alexandria Journal of Medicine 54 (2018) 215–227 We used to apply the triple phase technique as a routine CTU plaint of the patient, who was presented by acute renal colic. protocol in our department. First, a non-contrast phase was done, Hence, the importance for the technique to be supervised by the and then automated injection of 1.5 ml/kg intravenous nonionic radiologist.8,9 contrast media (Omnipaque 300) as a single bolus. Nephrographic Revision of the source images of the axial excretory phase is the phase was allowed to run 100 s after the bolus, then after 10– second step we used to do after checking the non-contrast phase. It 15 min we used to run the last excretory phase. The whole study is advised to use wide window measures- like bone window sets- CT examinations were done through Philips Brilliance 64 CT Scan- to review this excretory phase, as this helps to perfectly diagnose ner, Philips Medical System, Nederland. B.V. Veenpulis 4–5, 4684 subtle lesions that may be hidden by contrast material at the nar- PC Best, Netherlands. row soft tissue window sets. In our protocols, we used to do man- ual windows adjustment with different window length and width 3.3. Post-processing and image interpretation figures to attain different densities of the excreted contrast mate- rial, which helps to minimize the messing errors. Also routinely There are different post-processing data reconstructions pro- we used to do different reformat sets in coronal and sagittal recon- grams that vary from place to place for the urinary tract CT exam- structed images with the use of maximum intensity projection ination, however there are some commonly shared and agreed (MIP) tools.
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