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Multidetector CT Urography with Abdominal Compression and Three-Dimensional Reconstruction

¹ Both authors: Department of Radiology, Stanford University Medical Center, 300 Pasteur Dr., Rm. H1307, Stanford, CA 94305-5105.

View larger version (138K): [in a new window]   Fig. 1A. —45-year-old man, otherwise healthy, with 1-week history of gross hematuria while on considerable dose of nonsteroidal antiinflammatory medication. Scout image from CT scan with abdominal compression shows normal findings on bilateral nephrograms and good distention of collecting systems, despite balloon being slightly off center. This image provides overview of genitourinary tract similar to traditional excretory urogram.

View larger version (137K): [in a new window]   Fig. 1B. —45-year-old man, otherwise healthy, with 1-week history of gross hematuria while on considerable dose of nonsteroidal antiinflammatory medication. Scout image from CT scan after release of compression shows opacification of ureters.

View larger version (117K): [in a new window]   Fig. 1C. —45-year-old man, otherwise healthy, with 1-week history of gross hematuria while on considerable dose of nonsteroidal antiinflammatory medication. Twenty-millimeter-thick maximum-intensity-projection CT image through both kidneys and proximal ureters from enhanced CT data with compression shows distention and opacification of collecting systems. Calices, fornices, infundibula, and renal pelves are shown. Slight kinking of proximal ureter of no clinical significance can be seen on right.

View larger version (101K): [in a new window]   Fig. 1D. —45-year-old man, otherwise healthy, with 1-week history of gross hematuria while on considerable dose of nonsteroidal antiinflammatory medication. Double-oblique maximum-intensity-projection CT image shows right kidney in plane that is truly coronal to kidney rather than to patient.

View larger version (141K): [in a new window]   Fig. 2. —56-year-old woman being evaluated for episodic asymptomatic gross hematuria. Maximum-intensity-projection CT image generated from postcompression-release CT data shows exquisite detail of normal distal ureters bilaterally. Note ureteral jets and cloudlike appearance of contrast agent mixing with urine in bladder.

View larger version (84K): [in a new window]   Fig. 3A. —61-year-old man being evaluated for possible mass seen in left kidney on sonogram at another institution. Maximum-intensity-projection (A) and average-projection (B) CT images of left kidney generated from same contrast-enhanced CT with compression show duplication of collecting system and ureters. Average-projection CT image (B) is more conventional in appearance, resulting from summation of overlapping structures, but at cost of contrast resolution between opacified collecting system and adjacent structures.

View larger version (158K): [in a new window]   Fig. 3B. —61-year-old man being evaluated for possible mass seen in left kidney on sonogram at another institution.

View larger version (89K): [in a new window]   Fig. 3C. —61-year-old man being evaluated for possible mass seen in left kidney on sonogram at another institution. Maximum-intensity-projection CT image of duplicated distal left ureters shows orthotopic insertion of both ureters into bladder. Vascular calcification is incidentally seen.

View larger version (156K): [in a new window]   Fig. 4A. —16-year-old boy with hematuria. Right renal lesion was identified at another institution, and he was referred for further evaluation. Longitudinal sonogram of right kidney from another institution shows 1.3-cm mildly complex nearly anechoic upper pole structure (arrows) with acoustic enhancement and slight irregularity of its margins.

View larger version (122K): [in a new window]   Fig. 4B. —16-year-old boy with hematuria. Right renal lesion was identified at another institution, and he was referred for further evaluation. Unenhanced CT scan from another institution shows fluid-attenuation (8 H) structure (arrow) in upper pole of right kidney.

View larger version (141K): [in a new window]   Fig. 4C. —16-year-old boy with hematuria. Right renal lesion was identified at another institution, and he was referred for further evaluation. Contrast-enhanced CT scan from another institution shows enhancement of this structure (arrow, B and C) to 39 H, suggesting that it is solid in nature.

View larger version (98K): [in a new window]   Fig. 4D. —16-year-old boy with hematuria. Right renal lesion was identified at another institution, and he was referred for further evaluation. Delayed image from repeated contrast-enhanced CT scan at our institution shows dependent layering contrast agent (arrow) in this structure (B), implying communication with collecting system and showing that it is not solid.

View larger version (106K): [in a new window]   Fig. 4E. —16-year-old boy with hematuria. Right renal lesion was identified at another institution, and he was referred for further evaluation. Double-oblique maximum-intensity-projection CT image of right kidney shows that communication with upper pole collecting system is now clearly visible (arrow). Caliceal diverticula are narrow-necked outpouchings of renal collecting system ranging in size from few millimeters to several centimeters, which most commonly arise from fornix.

View larger version (116K): [in a new window]   Fig. 5A. —74-year-old man with microhematuria. Patient is on warfarin sodium for atrial fibrillation. Conventional radiographic tomogram shows no abnormal calcifications.

View larger version (131K): [in a new window]   Fig. 5B. —74-year-old man with microhematuria. Patient is on warfarin sodium for atrial fibrillation. Tomogram from excretory urography shows round contrast-filled structure in upper pole of left kidney that contains round filling defect (arrow) not seen on unenhanced image, consistent with radiolucent stone.

View larger version (97K): [in a new window]   Fig. 5C. —74-year-old man with microhematuria. Patient is on warfarin sodium for atrial fibrillation. Maximum-intensity-projection images from CT scans before (C) and after (D) contrast administration show to better advantage upper pole caliceal diverticulum, containing calculus (arrow, D). Two smaller calculi are also seen in interpolar region. Most commonly, caliceal diverticula are asymptomatic, but because of urinary stasis, complications can include both infection and formation of stones, which may become entrapped in diverticula.

View larger version (95K): [in a new window]   Fig. 5D. —74-year-old man with microhematuria. Patient is on warfarin sodium for atrial fibrillation.

View larger version (138K): [in a new window]   Fig. 6A. —53-year-old woman with one episode of crampy lower abdominal pain and gross hematuria 1 month earlier. Sonogram (not shown) at another institution revealed hydronephrosis but no definite stone. Patient is now asymptomatic but with persistent microhematuria. Twelve-millimeter-thick double-oblique minimum-intensity-projection CT image of right kidney shows moderate hydronephrosis (asterisk) well. Small simple cyst (arrow) is incidentally seen in upper pole.

View larger version (118K): [in a new window]   Fig. 6B. —53-year-old woman with one episode of crampy lower abdominal pain and gross hematuria 1 month earlier. Sonogram (not shown) at another institution revealed hydronephrosis but no definite stone. Patient is now asymptomatic but with persistent microhematuria. Maximum-intensity-projection CT image of distal ureters from postrelease CT scan shows normal course and caliber of distal left ureter but no opacification of right ureter. Calculus (arrow) is identified along course of distal right ureter.

View larger version (153K): [in a new window]   Fig. 6C. —53-year-old woman with one episode of crampy lower abdominal pain and gross hematuria 1 month earlier. Sonogram (not shown) at another institution revealed hydronephrosis but no definite stone. Patient is now asymptomatic but with persistent microhematuria. Curved planar reformation of right kidney and ureter from enhanced CT shows moderate hydroureteronephrosis resulting from obstructing calculus (arrow) in distal ureter. Delay in contrast excretion from right kidney is evident. In this patient, CT urography provided efficient complete examination of obstructed right urinary tract, obviating serial follow-up images over ensuing hours, which would have been necessary with conventional excretory urography.

View larger version (116K): [in a new window]   Fig. 7A. —57-year-old woman with long history of bilateral staghorn renal calculi after multiple percutaneous nephrolithotomy and lithotripsy procedures. Maximum-intensity-projection images of left kidney from unenhanced (A) and enhanced (B) CT scans show that contour of kidney is abnormal, and low-attenuation nonenhancing masses (asterisks) associated with abnormal calcifications are seen in upper pole and interpolar portion. Contrast agent fills dilated lower pole calices (arrows) on enhanced image (B).

View larger version (144K): [in a new window]   Fig. 7B. —57-year-old woman with long history of bilateral staghorn renal calculi after multiple percutaneous nephrolithotomy and lithotripsy procedures.

View larger version (111K): [in a new window]   Fig. 7C. —57-year-old woman with long history of bilateral staghorn renal calculi after multiple percutaneous nephrolithotomy and lithotripsy procedures. Three-millimeter thin-slab maximum-intensity-projection CT image of left kidney shows contrast agent in dilated calices (asterisks) and three rounded filling defects in upper pole (arrows), corresponding to sloughed papillae in collecting system.

View larger version (101K): [in a new window]   Fig. 7D. —57-year-old woman with long history of bilateral staghorn renal calculi after multiple percutaneous nephrolithotomy and lithotripsy procedures. Maximum-intensity-projection image of right kidney from contrast-enhanced CT scan shows severe hydroureteronephrosis and marked cortical thinning at upper and lower poles (arrows). Overall appearance is consistent with chronic atrophic pyelonephritis.

View larger version (144K): [in a new window]   Fig. 8A. —45-year-old man with 15-year history of interstitial cystitis now with asymptomatic, but persistent, microhematuria. Postrelease scout images from CT scan (A) and average-projection image (B) from contrast-enhanced CT scan show mild right hydroureteronephrosis to level of distal ureter, with abrupt termination of contrast column and filling defect (arrows) perceptible.

View larger version (148K): [in a new window]   Fig. 8B. —45-year-old man with 15-year history of interstitial cystitis now with asymptomatic, but persistent, microhematuria.

View larger version (146K): [in a new window]   Fig. 8C. —45-year-old man with 15-year history of interstitial cystitis now with asymptomatic, but persistent, microhematuria. Maximum-intensity-projection CT image of distal ureters better depicts circumferential irregular thickening of distal right ureter (arrows), that resulted in obstruction. Surgical specimen yielded high-grade transitional cell carcinoma.

View larger version (100K): [in a new window]   Fig. 9A. —41-year-old man with one episode of gross painless hematuria. Coronal maximum-intensity-projection image of right kidney from contrast-enhanced CT scan with compression shows no abnormal findings. Two-centimeter exophytic upper pole mass was seen on anterior sliding thin-slab maximum-intensity-projection CT images (not shown). Because of anterior location, small size, and lack of deformity of collecting structures, detection with conventional excretory urography would be unlikely.

View larger version (95K): [in a new window]   Fig. 9B. —41-year-old man with one episode of gross painless hematuria. Sagittal maximum-intensity-projection image of right kidney from same contrast-enhanced CT scan shows that 2-cm exophytic mass (arrow) is clearly visible, extending from anterior margin of upper pole. Subsequent resection yielded grade 3 clear cell carcinoma with distinct margins.

View larger version (97K): [in a new window]   Fig. 10. —36-year-old woman with intermittent left-flank pain. Five-millimeter average-projection image of left kidney generated from contrast-enhanced CT data shows well-circumscribed 8-mm fat-attenuation mass (arrow) in upper pole, consistent with benign angiomyolipoma.

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