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DR NIGEL COWAN DM FRCP FRCR
The Queen Alexandra Hospital
PORTSMOUTH, UK
email: nigel.cowan@porthosp.nhs.uk
DR NIGEL COWAN DM FRCP FRCR
The Queen Alexandra Hospital
PORTSMOUTH, UK
email: nigel.cowan@porthosp.nhs.uk
CT UROGRAPHY���
& ���
BOLUS SPLITTING?
Split bolus CT urography first reported by:
• Chow LC & Sommer FG 2001
• MulPdetector CT urography with abdominal compression and three dimensional recontrucPon
• American Journal of Roentgenology
Chow & Sommer 2001
• Novel • InnovaPve
• Fashionable
Just because we can
Mt. Everest has around 200 dead bodies on the mountain. It is nearly impossible for recovery of a body off the mountain. Most of the bodies are in the same exact position they were when they died. Perfectly preserved in time because of the cold. Along the route up to the summit climbers will pass all these
bodies. There are bodies over 50 years old that look like they were placed there yesterday.
doesn’t mean we should...
Mt. Everest has around 200 dead bodies on the mountain. It is nearly impossible for recovery of a body off the mountain. Most of the bodies are in the same exact position they were when they died. Perfectly preserved in time because of the cold. Along the route up to the summit climbers will pass all these
bodies. There are bodies over 50 years old that look like they were placed there yesterday.
PerspecPve
What are we trying to achieve?
Clinical ques9on?
Disease prevalence
Risk stra9fica9on
Designing an imaging strategy
Risk factors
Treatment?
Diagnos9c accuracy
Test
Result interpretaPon
What are we trying to achieve?
DISEASE Cowan et al 2012 Khadra et al 1999
Edwards et al 2006 % Bladder cancer 16.5-‐19.3
Stones 3.2-‐16.3 Renal cell cancer 0.9-‐2.4
UT urothelial cancer 0.1-‐2.2
UTI 0-‐13.0 Prostate cancer 0.6-‐3.5
ADPKD 0-‐0.3 Chronic pyelonephriPs 0-‐0.2 Nephrological disease 0-‐10.3
No disease found 52.5-‐72.2
Complicated relaPonship between
DiagnosPc accuracy
Contrast
Dose “X factor”
A convenPonal protocol for CT urography?
NC NG EX
No iv CM 50 -‐ 100 s iv CM 750 s iv CM
Dose
• 6 mSv per whole series 15 mSv (2.5) 12 mSv (2) 20% saving
Some Split Bolus Protocols
1 2 3
Chow et al 2001 (174) 40 80 -‐
Cowan et al 2007 (120) 100 50 -‐
Knox et al 2010 (7) 40 30 80
Kekelidze et al 2010 (81) 30 50 65
78F, VH
Triple bolus CT urography
Knox et al Eur Radiol 2010, Kekelidze et al 2010 Radiology
x3 bolus
inner medulla
outer medulla
cortex
CM
CM CM
Phases of contrast media processing in the kidney
CM
Ullrich G. Mueller-Lisse, M.D., M.B.A.
• Nonenhanced 0 s • Arterial 15 -‐25 s ü Urothelial 30-‐50 s • Portal venous 70 s • Nephrographic 100 s • Excretory 300 – 900 s • Delayed excretory > 900 s
60 -‐70 s references
Kupershmidt AJR 2011; 197:424–428 Metser Radiology 2012; 264:110-‐118
Comparing opPmised 60-‐70s acquisiPons with subopPmal excretory-‐phase imaging
Bladder • Kim et al 2004 Radiology • Park et al 2007 Radiology • Jinzaki et al 2007 AJR
CT urography for diagnosis of UTUC: Are both nephrographic and excretory-‐phases necessary?
NG-‐phase EX-‐phase NG+EX-‐phases
R1 R2 R1 R2 R1 R2
Se 0.88 0.84 0.79 0.89 0.88 0.89
Sp 0.98 0.97 0.98 0.98 0.99 0.99
AUC 0.95 0.94 0.91 0.95 0.95 0.96
Takeuchi et al 2015 AJR 205 320 – 327 Conclusion -‐ The nephrographic and excretory-‐phases are complimentary for the detecPon of UTUC
DiagnosPc accuracy of CT urography for UTUC
Se Sp PPV NPV
CTU inc. ex-‐phase 0.67 – 1.0 0.93 – 0.99 0.50 – 0.87 0.97 – 1.0
CTU uro-‐phase 1.0 0.99 0.67 1.0
Urothelial-‐phase
Which bolus protocol should I use?
Bolus protocol IndicaPon
1 Single Visible haematuria (paPents at high risk for UTUC and RCC)
2 Double ?
3 Triple Living related kidney donor assessment Percutaneous nephrolithotomy assessment
Complicated relaPonship between
DiagnosPc accuracy
Contrast
Dose “X factor”
Complicated relaPonship between diagnosPc accuracy, contrast , dose and “X factor”
DiagnosPc accuracy Contrast
Dose X factor
X factor
Looking forward
Single series CT urography Single bolus
THANK YOU
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