AJR 2001; 177:849-855
© American Roentgen Ray Society
Multidetector CT Urography with Abdominal Compression and Three-Dimensional Reconstruction
Lawrence C. Chow1 and
F. Graham Sommer1
1
Both authors: Department of Radiology, Stanford University Medical Center, 300
Pasteur Dr., Rm. H1307, Stanford, CA 94305-5105.
Received February 6, 2001;
accepted after revision April 24, 2001.
Address correspondence to L. C. Chow.
Introduction
Painless hematuria is one of the most important warning signs of urologic
malignancy, and whereas its causes are numerous, including benign entities,
more ominous diagnoses must be excluded by urologic and radiologic evaluation.
With the development of helical and, more recently, multidetector CT,
unenhanced CT has largely replaced excretory urography in the evaluation of
patients presenting with possible renal colic. In most institutions, however,
excretory urography remains the mainstay in evaluating patients who present
with painless hematuria. Multidetector CT is ideally suited for dynamic
multiphase scans and allows the acquisition of isotropic or near-isotropic
image data sets, making true multiplanar reconstruction of CT data a reality.
These attributes, in conjunction with the traditional strengths of CT in the
imaging of the renal parenchyma, make multidetector CT well suited for
evaluation of patients with hematuria and provide a single examination capable
of imaging both the renal parenchyma and collecting systems. At our
institution, CT urography has virtually replaced conventional excretory
urography in the evaluation of patients with hematuria and has proven
successful in depicting a wide range of disease affecting the urinary
tract.
Technique of Data Acquisition and Postprocessing
CT urography is performed with a Light-Speed CT scanner (General Electric
Medical Systems, Milwaukee, WI) and the following protocol: scans are obtained
in three phases—unenhanced, enhanced with abdominal compression, and
postrelease. Initial unenhanced images are obtained from the diaphragm to the
symphysis pubis with 5-mm collimation and 2.5-mm reconstruction interval.
Subsequently, a 40-mL bolus of Omnipaque 300 (Nycomed-Amersham, Princeton, NJ)
is administered at 2 mL/sec via an antecubital IV with an Envision CT power
injector (Medrad, Indianola, PA), and abdominal compression is applied. After
a 2-min delay, the remaining 80 mL of contrast agent is administered at an
injection rate of 2 mL/sec. CT scans are obtained after a 90-sec delay from
the diaphragm to the iliac crests with 2.5-mm collimation and a 1.25-mm
reconstruction interval. A scout image is then obtained of the abdomen and
pelvis. Compression is released, and a CT scan is immediately obtained from
the iliac crests to the symphysis pubis with 2.5-mm collimation and 1.25-mm
interval. A final scout image of the abdomen and pelvis is then obtained. All
CT images are obtained helically in HiSpeed mode (pitch, 6:0).
Three-dimensional (3D) reconstruction of the data includes both thin- and
thick-slab maximum-intensity-projection images. Sliding thin-slab (5-mm)
maximum-intensity-projection coronal oblique images in a plane as en
face to the kidney as possible are generated from both unenhanced and
enhanced data for each kidney individually. Additionally, anteroposterior
thick-slab (35-50 mm) maximum-intensity-projection images are generated of the
kidneys individually and collectively from the enhanced compression data.
Finally, a maximum-intensity-projection image of the distal ureters and
urinary bladder from the third phase is generated. Additional
maximum-intensity-projection, minimum-intensity-projection,
average-projection, and curved planar reformation images are generated on an
individual as-needed basis. All 3D reconstructions are generated on an
Advantage Windows 3.1 dedicated workstation (General Electric Medical
Systems). Final image adjustment is performed with PhotoDraw 1.0 image
software (Microsoft, Redmond, WA).
Normal Anatomy
The benefit of CT urography is its ability to depict the normal urinary
tract anatomy, including both the renal parenchyma and the collecting
structures and ureters. Unenhanced images are obtained to evaluate the
presence of calcifications and to allow determination of unenhanced
attenuation values for any focal lesions in the kidneys. To simplify the
procedure and to reduce the number of phases necessary, a splitbolus technique
of contrast administration is used, resulting in scanning during a
simultaneous nephrographic and excretory phase. Nephrographic and excretory
phase images have previously been shown to be superior to corticomedullary
phase images in the detection and characterization of renal masses
[1].
With abdominal compression, good contrast distention of the collecting
system can be achieved that is comparable to or superior to that of
conventional excretory urography
[2,
3] (Figs.
1A,1B,1C,1D
and 2). Three-dimensional
reformation of CT data in the coronal plane provides a more familiar
representation of the collecting system, showing the calices, fornices,
infundibula, renal pelvis, and ureters in continuity. To our knowledge, in at
least one study, 3D reformatted images have been shown to be acceptable
alternatives to or preferable to conventional excretory urography images when
judged by experienced urologists
[2].
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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.
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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.
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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.
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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.
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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.
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Anomalies and Abnormalities
Because CT urography can image both the renal parenchyma and urothelium, a
wide range of disease can be identified. In our experience, CT urography has
been successful in clearly depicting anatomic variants, stone disease,
inflammatory processes, and benign and malignant neoplasms.
As with traditional CT, congenital anomalies of renal position, number, and
form are easily appreciated with CT urography. Duplications of the collecting
system, however, are more difficult to appreciate on conventional CT and can
easily be missed because opacification of the ureters is usually incomplete.
Furthermore, the findings of a duplicated system are more obvious on a single
coronal image that depicts the collecting system in its entirely (Fig.
3A,3B,3C).
Although duplications of the collecting system are relatively rare, with an
autopsy incidence of partial duplications in one in 150 cases and complete
duplications, one in 500 cases
[4], knowledge of the presence
of a duplication before a procedure or intervention is invaluable to the
urologist. Similarly, coronally reformatted CT urograms can provide good
delineation of a caliceal diverticulum and show its communication with the
collecting system (Figs.
4A,4B,4C,4D,4E
and
5A,5B,5C,5D).
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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Although urinary tract stone disease generally presents with a classic
clinical scenario of colicky flank pain and hematuria, for which the
appropriate initial and often only imaging evaluation required is unenhanced
helical CT, CT urography can be useful in the evaluation of chronic stone
disease by providing information regarding the number and size of calculi and
their relationship to and effect on the collecting system (Figs.
5A,5B,5C,5D,6A,6B,6C,7A,7B,7C,7D).
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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.
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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.
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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.
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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).
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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.
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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.
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Various infectious and noninfectious inflammatory entities can result in
hematuria. Although imaging is usually not indicated in acute bacterial
pyelonephritis or cystitis, CT urography could be helpful in the evaluation of
more chronic infectious processes such as renal tuberculosis, chronic
pyelonephritis, and xanthogranulomatous pyelonephritis (Fig.
7A,7B,7C,7D),
in which long-term sequelae involve both renal parenchyma and the collecting
system.
Malignancy of both the urothelium and the renal parenchyma may present with
hematuria. Approximately 7-8% of renal malignancies develop in the collecting
system. Transitional cell carcinoma most commonly presents as an intraluminal
filling defect or with obstruction (Fig.
8A,8B,8C),
in which case renal function may be inadequate to allow visualization with
excretory urography. In any patient in whom transitional cell carcinoma is
suspected, the entire urothelium must be examined because of the multicentric
nature of the tumor. In the bladder, cystoscopy provides the most direct and
most thorough examination. The renal collecting systems and ureters, however,
have traditionally been examined by excretory urography. CT urography allows
reconstruction of images in any plane at user-definable slice thicknesses.
Maximum-intensity-projection CT images provide superior contrast resolution in
visualizing the opacified collecting structures.
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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.
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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.
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Hematuria is the most common sign of renal adenocarcinoma, occurring in
more than half of patients [4].
Excretory urography is an insensitive test for the detection of small renal
neoplasms [5,
6], and CT can detect a
substantial number of renal parenchymal masses missed by excretory urography
[7]. CT urography provides
information similar to conventional CT in the assessment of renal masses
(Figs.
9A,9B,
and 10). Unenhanced images
ensure evaluation of the enhancement characteristics of solid renal lesions,
and coronal reformatted images are useful in visualizing the relationships of
renal lesions with adjacent anatomy and as an aid to surgical planning.
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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.
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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.
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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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Future Directions
Whereas CT urography can clearly provide exquisite depiction of the
kidneys, collecting systems, and ureters, it is an evolving technique and,
like all new strategies, is subject to controversy. The optimal method is
still subject to debate, and as many different protocols are probably being
used as there are institutions that perform CT urography. Several concepts
remain universally important, however, despite the specific protocol being
used. Evaluation of the collecting system requires abdominal compression to
achieve adequate distention. Additionally, it is important to interpret the
images with different window and level settings appropriate for the target
structure being examined. This interpretation is particularly relevant in
evaluating the collecting system because small filling defects or urothelial
lesions can be obscured by dense intraluminal contrast agents. Furthermore,
despite the usefulness and simplicity of 3D reformatted images, careful
interpretation of the axial source images remains imperative.
Although it seems evident, in theory, that CT urography would be an ideal
method to study patients with hematuria, its ability to detect disease has not
yet been proven by prospective studies. Critics would argue that CT still
lacks the spatial resolution of conventional radiography, and although this
argument is true, recent advances in multidetector CT technology now allow
section thicknesses as narrow as 0.5 mm. Additionally, forthcoming advances
hold promise for improving the information provided by scout images. Perhaps
it is premature to dismiss the conventional excretory urogram completely, but
we are optimistic about the future of CT urography because of the technologic
advances and research that are quickly bringing this technique into the
mainstream.
Acknowledgments
We thank Laura Logan and Mark Sofilos for their valuable technical
expertise and effort in generating the 3D reformatted images shown in this
manuscript.
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S. G. Silverman, S. A. Akbar, K. J. Mortele, K. Tuncali, J. G. Bhagwat, and J. L. Seifter
Multi-Detector Row CT Urography of Normal Urinary Collecting System: Furosemide versus Saline as Adjunct to Contrast Medium
Radiology,
September 1, 2006;
240(3):
749 - 755.
[Abstract]
[Full Text]
[PDF]
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G. S. Sudakoff, D. P. Dunn, R. S. Hellman, M. A. Laguna, C. R. Wilson, R. W. Prost, D. C. Eastwood, and H. J. Lim
Opacification of the Genitourinary Collecting System During MDCT Urography with Enhanced CT Digital Radiography: Nonsaline Versus Saline Bolus
Am. J. Roentgenol.,
January 1, 2006;
186(1):
122 - 129.
[Abstract]
[Full Text]
[PDF]
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S. Kawamoto, K. M. Horton, and E. K. Fishman
Opacification of the Collecting System and Ureters on Excretory-Phase CT Using Oral Water as Contrast Medium
Am. J. Roentgenol.,
January 1, 2006;
186(1):
136 - 140.
[Full Text]
[PDF]
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G. Sommer, E. W. Olcott, L. C. Chow, R. R. Saket, and P. Schraedley-Desmond
Measurement of Renal Extraction Fraction with Contrast-enhanced CT
Radiology,
September 1, 2005;
236(3):
1029 - 1033.
[Abstract]
[Full Text]
[PDF]
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J Richenberg and P Thompson
Haematuria
Imaging,
August 1, 2005;
17(1):
34 - 43.
[Full Text]
[PDF]
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E. M. Caoili, R. H. Cohan, P. Inampudi, J. H. Ellis, R. B. Shah, G. J. Faerber, and J. E. Montie
MDCT Urography of Upper Tract Urothelial Neoplasms
Am. J. Roentgenol.,
June 1, 2005;
184(6):
1873 - 1881.
[Abstract]
[Full Text]
[PDF]
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E. M. Caoili, P. Inampudi, R. H. Cohan, and J. H. Ellis
Optimization of Multi-Detector Row CT Urography: Effect of Compression, Saline Administration, and Prolongation of Acquisition Delay
Radiology,
April 1, 2005;
235(1):
116 - 123.
[Abstract]
[Full Text]
[PDF]
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G. S. Sudakoff, M. Guralnick, P. Langenstroer, W. D. Foley, K. L. Cihlar, J. S. Shakespear, and W. A. See
CT Urography of Urinary Diversions with Enhanced CT Digital Radiography: Preliminary Experience
Am. J. Roentgenol.,
January 1, 2005;
184(1):
131 - 138.
[Abstract]
[Full Text]
[PDF]
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E. Ghersin, O. R. Brook, S. Meretik, J. K. Kaftori, A. Ofer, M. A. Amendola, and A. Engel
Antegrade MDCT Pyelography for the Evaluation of Patients with Obstructed Urinary Tract
Am. J. Roentgenol.,
December 1, 2004;
183(6):
1691 - 1696.
[Abstract]
[Full Text]
[PDF]
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M Noroozian, R H Cohan, E M Caoili, N C Cowan, and J H Ellis
Multislice CT urography: state of the art
Br. J. Radiol.,
December 1, 2004;
77(suppl_1):
S74 - S86.
[Abstract]
[Full Text]
[PDF]
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A. Kawashima, T. J. Vrtiska, A. J. LeRoy, R. P. Hartman, C. H. McCollough, and B. F. King Jr
CT Urography
RadioGraphics,
October 1, 2004;
24(suppl_1):
S35 - S54.
[Abstract]
[Full Text]
[PDF]
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E. M. Caoili, R. H. Cohan, A. Kawashima, and A. J. LeRoy
Invited Commentary * Authors' Response
RadioGraphics,
October 1, 2004;
24(suppl_1):
S55 - S58.
[Full Text]
[PDF]
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S. Sheth and E. K. Fishman
Multi-Detector Row CT of the Kidneys and Urinary Tract: Techniques and Applications in the Diagnosis of Benign Diseases
RadioGraphics,
March 1, 2004;
24(2):
e20 - e20.
[Abstract]
[Full Text]
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J.-K. Kim, S.-Y. Park, H.-j. Kim, C.-S. Kim, H.-J. Ahn, T.-Y. Ahn, and K.-S. Cho
Living Donor Kidneys: Usefulness of Multi-Detector Row CT for Comprehensive Evaluation
Radiology,
December 1, 2003;
229(3):
869 - 876.
[Abstract]
[Full Text]
[PDF]
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F. V. Coakley and B. M. Yeh
Invited Commentary
RadioGraphics,
November 1, 2003;
23(6):
1455 - 1456.
[Full Text]
[PDF]
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V. Kundra and P. M. Silverman
Imaging in the Diagnosis, Staging, and Follow-Up of Cancer of the Urinary Bladder
Am. J. Roentgenol.,
April 1, 2003;
180(4):
1045 - 1054.
[Full Text]
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Top
Introduction
Technique of Data Acquisition...
