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Routine Use of Tomography in Excretory Urography
Vol. 110, December
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
Printed in U.S.A.
ROUTINE USE OF TOMOGRAPHY IN EXCRETORY UROGRAPHY LAURENCE F. GREENE, JOSEPH W. SEGURA, ROBERT R. HATTERY
AND
GLEN W. HARTMAN
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
For the past 3 years we have used tomography routinely during excretory urography and we believe it has resulted in significant improvement in urologic diagnosis. Without tomography, urographic diagnosis frequently is dependent solely on
Tomography usually will correct these deficiencies. In addition, in conventional excretory urography the pelviocaliceal system and renal outlines frequently are obscured by bowel contents, by overlying soft tissues, by barium, by calcified cartilages
FIG. 1. A, scout film. B, conventional urogram shows urinary tract obscured by bowel content. C, tomogram shows that upper part of urinary tract is normal.
FIG. 2. A, scout film. B, conventional urogram shows normal pelviocaliceal systems but renal parenchyma and outlines are not visualized. C, tomogram shows normal renal parenchyma and outlines.
the interpretation of fortuitous encroachment or deformity of the pelviocaliceal system by the pathologic lesion. Delineation of the renal parenchyma and renal outlines is often impossible.
and so on. These obfuscating factors are largely eliminated by tomography. We will describe our routine urographic technique. A conventional roentgenogram of the kidneys, ureters and bladder and a single 50-degree linear tomogram are obtained to determine exposure factors and necessary levels of subsequent tomograms. These are viewed by the radiologist
Accepted for publication June 15, 1973. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1973.
714
ROUTINE USE OF TOlv!OG-RAPH\'
EXCRETORY UROGRAPH'/
715
FIG. 3. A, scout film. B, conventional urogram shows that pelviocaliceal system and renal outlines, particularly on left side, are obscured by calcified costal cartilages. C, tomogram shows calcified adrenal tumor (arrows).
FIG. 4. A, scout film. B, conventional urogram shows status of left kidney is indeterminate. C, tomogram shows left renal infarct.
before injection of contrast medium. We inject 50 ml. sodium diatrizoate and meglumine diatrizoate* unless a larger dose is indicated. During the nephrographic phase (2 to :3 minutes after tion), tomograms are obtained to define the renal outlines and Ureteral compression is then applied and a localized view of the kidneys is obtained at 8 minutes. The roentgenogram is viewed by the radiologist and, if the pelviocaliceal system is obscured, a short arc tomogram is obtained. If the pelviocaliceal system is well visualized, the ureteral compression is released and a 14 by 17-inch film is obtained to demonstrate the
kidneys and ureters. Films of the bladder are obtained at 20 minutes. The addition of tomography has been invaluable in 2 broad areas: 1) it has salvaged normal and abnormal urographic studies that otherwise would have been indeterminate and 2) it has demonstrated abnormalities that were not apparent on conventional urograms.
* Renovist II, E. R. Squibb & Sons, 909 Third Avenue, New York, New York 10022.
SALVAGE OF UROGRAPHIC STUDIES BY ADDITION OF TOMOGRAPHY
Frequently, the depiction of the urinary tract in conventional excretory urography is so poor that the study must be considered indeterminate. In such cases tomography may be helpful by 1)
716
GREENE AND ASSOCIATES
demonstrating that the urinary tract is normal or 2) suggesting the presence of a lesion. In figure 1 the condition of the urinary tract is indeterminate on conventional urograms because the pelviocaliceal systems are obscured by bowel content but the normalcy of the kidneys is clearly demonstrated on the tomogram. Similarly in figure 2, although the pelviocaliceal systems are well visualized and appear normal, the conventional urogram must be considered indeterminate because of the complete obfuscation of the renal parenchyma and renal outlines by bowel content. The study is salvaged and the normalcy of the urinary tract is established by the tomograms, which clearly depict the renal parenchyma and renal outlines. Likewise tomography can demonstrate renal lesions that would have gone undetected on conventional urograms and such urograms would have been considered indeterminate. Included in this category are generalized or partial renal atrophy, calculus, renal anomalies, renal cysts, adrenal tumors (fig. 3) and renal infarcts (fig. 4). Tornograms have demonstrated masses subsequently proved to be hypernephromas (fig. 5).
DEMONSTRATION OF LESIONS IN EXCRETORY UlWGRAPHY THAT WOULD HAVE BEEN CONSIDERED NORMAL
By its ability to indicate the renal parenchyma and renal outlines, tomography can demonstrate renal masses that would not have been detected in conventional excretory urography; such urograms would have been interpreted as normal. The majority of these lesions proved to be renal cysts, as might be expected because of the relative incidences of renal cysts and hypernephromas (fig. 6).
The detection of masses, subsequently proved to be hypernephromas, that would have been overlooked without tomography is of particular significance. The masses were small, generally 2 to 3 cm. or less in diameter, did not affect the pelviocaliceal system and usually were recognized by a bulge in the renal outline discernible only on the tomograms. They were further evaluated by bolus nephrotomography or renal arteriography and proved to be hypernephromas by an operation. Hypernephromas were discovered serendipitously in patients who had no stigma of malig-
FIG. 5. A, scout film. B, conventional urogram shows urinary tract is obscured by bowel content. C, tomogram shows mass in lower pole of right kidney. D, bolus nephrotomogram reveals hypernephroma of right kidney proved by operation.
IN EXCRETORv UROGRAPHY
7 -,j_
RETROSPECTIVE STCOIES
studies were made of the value of tomography in detecting renal masses. For this purpose, 100 urograms in which renal masses had been detected with the aid of tomography were reviewed without the tomograms. A number of urograms without renal masses were interspersed in the sample. Of the 100 urograms of patients known to have a renal mass, the mass could be detected without the aid of tomography in 54. Of the 46 cases in which the renal mass was not detected without tomography, the conventional urogram was considered to be indeterminate in 18. This finding is not particularly disturbing because conceivably the urographic study might have been repeated or a different radiographic study might have been undertaken. However, in the remaining 28 cases the conventional urogram was considered normal and the presence of a renal mass in this group of patients would have gone undetected. In a separate but similar retrospective study of the adjunctive value of tomograms made at this clinic, the size of renal masses was considered. 1 For this purpose 65 urograms in which renal masses had been detected with the aid of tomography were reviewed without the tomograms. Thirty-three per cent of renal masses measuring less than 2.5 cm. in diameter and 20 per cent measuring 2.5 to 4.5 cm. were not detected in conventional excretory urography. All masses larger than 5.0 cm. were detected on conventional urograms without tomograms. It is apparent from both studies that routine tomography used as an adjunct to conventional excretory urography is invaluable in detecting renal masses. More particularly, this technique will increase the detection of small masses that might represent early, curable hypernephromas. SUMMARY
FIG. 6. A, scout film. B, conventional urogram shows normal appearing upper urinary tract. C, tomogram reveals left renal cyst, which was proved by operation.
nancy. Examples of urograms of patients who were being studied for other reasons are shown in figures 7 to 11. In each case the malignancy was stage A and, in our opinion, achieved a cure.
Orographic diagnosis has been significantly improved by the routine addition of tomography. This technique has resulted in the salvage of urographic studies that otherwise would have been considered indeterminate. Likewise, tomography has demonstrated lesions when conventional urograms, without tomography, would have been considered normal. 1
Powell, D. F.: Personal communication.
718
GREENE AND ASSOCIATES
FIG. 7. Urogram of 50-year-old woman made because of urinary infection. A, scout film. B, conventional urogram shows normal appearing upper urinary tract. C, tomogram shows mass in right kidney, D, right hypernephroma.
FIG. 8. Urogram of 48-year-old woman made because of hypertension. A, scout film. B, conventional urogram shows normal appearing right kidney. C, tomogram shows mass in right kidney. D, right hypernephroma.
ROUTINE
OF
EXCRETORY UROGRAPHY
7i0 'J_J
FIG. 9. Urogram of 45-year-old woman made because ofhypercalcemia. A, scout film. B, conventional urogram shows normal appearing urinary tract. C, tomogram shows mass in right kidney. D, right hypernephroma.
FIG. 10. Urogram of 56-year-old man made because of prostatism. A, scout film. B, conventional urogram shows normal appearing urinary tract. C, tomogram shows mass in lower pole of right kidney. D, right hypernephroma.
FIG. l 1. Urogram of 45-year-old man made because of urinary calculi. A, scout film. B, conventional urogram shows normal appearing urinary tract. C, tomogram shows mass in lower pole ofleft kidney. D, left hypernephroma.
720
THE JOURNAL OF UROLOGY
Copyright © 1973 by The Williams & Wilkins Co.
Printed in U.S.A.
ROUTINE USE OF TOMOGRAPHY IN EXCRETORY UROGRAPHY LAURENCE F. GREENE, JOSEPH W. SEGURA, ROBERT R. HATTERY
AND
GLEN W. HARTMAN
From the Mayo Clinic and Mayo Foundation, Rochester, Minnesota
For the past 3 years we have used tomography routinely during excretory urography and we believe it has resulted in significant improvement in urologic diagnosis. Without tomography, urographic diagnosis frequently is dependent solely on
Tomography usually will correct these deficiencies. In addition, in conventional excretory urography the pelviocaliceal system and renal outlines frequently are obscured by bowel contents, by overlying soft tissues, by barium, by calcified cartilages
FIG. 1. A, scout film. B, conventional urogram shows urinary tract obscured by bowel content. C, tomogram shows that upper part of urinary tract is normal.
FIG. 2. A, scout film. B, conventional urogram shows normal pelviocaliceal systems but renal parenchyma and outlines are not visualized. C, tomogram shows normal renal parenchyma and outlines.
the interpretation of fortuitous encroachment or deformity of the pelviocaliceal system by the pathologic lesion. Delineation of the renal parenchyma and renal outlines is often impossible.
and so on. These obfuscating factors are largely eliminated by tomography. We will describe our routine urographic technique. A conventional roentgenogram of the kidneys, ureters and bladder and a single 50-degree linear tomogram are obtained to determine exposure factors and necessary levels of subsequent tomograms. These are viewed by the radiologist
Accepted for publication June 15, 1973. Read at annual meeting of American Urological Association, New York, New York, May 13-17, 1973.
714
ROUTINE USE OF TOlv!OG-RAPH\'
EXCRETORY UROGRAPH'/
715
FIG. 3. A, scout film. B, conventional urogram shows that pelviocaliceal system and renal outlines, particularly on left side, are obscured by calcified costal cartilages. C, tomogram shows calcified adrenal tumor (arrows).
FIG. 4. A, scout film. B, conventional urogram shows status of left kidney is indeterminate. C, tomogram shows left renal infarct.
before injection of contrast medium. We inject 50 ml. sodium diatrizoate and meglumine diatrizoate* unless a larger dose is indicated. During the nephrographic phase (2 to :3 minutes after tion), tomograms are obtained to define the renal outlines and Ureteral compression is then applied and a localized view of the kidneys is obtained at 8 minutes. The roentgenogram is viewed by the radiologist and, if the pelviocaliceal system is obscured, a short arc tomogram is obtained. If the pelviocaliceal system is well visualized, the ureteral compression is released and a 14 by 17-inch film is obtained to demonstrate the
kidneys and ureters. Films of the bladder are obtained at 20 minutes. The addition of tomography has been invaluable in 2 broad areas: 1) it has salvaged normal and abnormal urographic studies that otherwise would have been indeterminate and 2) it has demonstrated abnormalities that were not apparent on conventional urograms.
* Renovist II, E. R. Squibb & Sons, 909 Third Avenue, New York, New York 10022.
SALVAGE OF UROGRAPHIC STUDIES BY ADDITION OF TOMOGRAPHY
Frequently, the depiction of the urinary tract in conventional excretory urography is so poor that the study must be considered indeterminate. In such cases tomography may be helpful by 1)
716
GREENE AND ASSOCIATES
demonstrating that the urinary tract is normal or 2) suggesting the presence of a lesion. In figure 1 the condition of the urinary tract is indeterminate on conventional urograms because the pelviocaliceal systems are obscured by bowel content but the normalcy of the kidneys is clearly demonstrated on the tomogram. Similarly in figure 2, although the pelviocaliceal systems are well visualized and appear normal, the conventional urogram must be considered indeterminate because of the complete obfuscation of the renal parenchyma and renal outlines by bowel content. The study is salvaged and the normalcy of the urinary tract is established by the tomograms, which clearly depict the renal parenchyma and renal outlines. Likewise tomography can demonstrate renal lesions that would have gone undetected on conventional urograms and such urograms would have been considered indeterminate. Included in this category are generalized or partial renal atrophy, calculus, renal anomalies, renal cysts, adrenal tumors (fig. 3) and renal infarcts (fig. 4). Tornograms have demonstrated masses subsequently proved to be hypernephromas (fig. 5).
DEMONSTRATION OF LESIONS IN EXCRETORY UlWGRAPHY THAT WOULD HAVE BEEN CONSIDERED NORMAL
By its ability to indicate the renal parenchyma and renal outlines, tomography can demonstrate renal masses that would not have been detected in conventional excretory urography; such urograms would have been interpreted as normal. The majority of these lesions proved to be renal cysts, as might be expected because of the relative incidences of renal cysts and hypernephromas (fig. 6).
The detection of masses, subsequently proved to be hypernephromas, that would have been overlooked without tomography is of particular significance. The masses were small, generally 2 to 3 cm. or less in diameter, did not affect the pelviocaliceal system and usually were recognized by a bulge in the renal outline discernible only on the tomograms. They were further evaluated by bolus nephrotomography or renal arteriography and proved to be hypernephromas by an operation. Hypernephromas were discovered serendipitously in patients who had no stigma of malig-
FIG. 5. A, scout film. B, conventional urogram shows urinary tract is obscured by bowel content. C, tomogram shows mass in lower pole of right kidney. D, bolus nephrotomogram reveals hypernephroma of right kidney proved by operation.
IN EXCRETORv UROGRAPHY
7 -,j_
RETROSPECTIVE STCOIES
studies were made of the value of tomography in detecting renal masses. For this purpose, 100 urograms in which renal masses had been detected with the aid of tomography were reviewed without the tomograms. A number of urograms without renal masses were interspersed in the sample. Of the 100 urograms of patients known to have a renal mass, the mass could be detected without the aid of tomography in 54. Of the 46 cases in which the renal mass was not detected without tomography, the conventional urogram was considered to be indeterminate in 18. This finding is not particularly disturbing because conceivably the urographic study might have been repeated or a different radiographic study might have been undertaken. However, in the remaining 28 cases the conventional urogram was considered normal and the presence of a renal mass in this group of patients would have gone undetected. In a separate but similar retrospective study of the adjunctive value of tomograms made at this clinic, the size of renal masses was considered. 1 For this purpose 65 urograms in which renal masses had been detected with the aid of tomography were reviewed without the tomograms. Thirty-three per cent of renal masses measuring less than 2.5 cm. in diameter and 20 per cent measuring 2.5 to 4.5 cm. were not detected in conventional excretory urography. All masses larger than 5.0 cm. were detected on conventional urograms without tomograms. It is apparent from both studies that routine tomography used as an adjunct to conventional excretory urography is invaluable in detecting renal masses. More particularly, this technique will increase the detection of small masses that might represent early, curable hypernephromas. SUMMARY
FIG. 6. A, scout film. B, conventional urogram shows normal appearing upper urinary tract. C, tomogram reveals left renal cyst, which was proved by operation.
nancy. Examples of urograms of patients who were being studied for other reasons are shown in figures 7 to 11. In each case the malignancy was stage A and, in our opinion, achieved a cure.
Orographic diagnosis has been significantly improved by the routine addition of tomography. This technique has resulted in the salvage of urographic studies that otherwise would have been considered indeterminate. Likewise, tomography has demonstrated lesions when conventional urograms, without tomography, would have been considered normal. 1
Powell, D. F.: Personal communication.
718
GREENE AND ASSOCIATES
FIG. 7. Urogram of 50-year-old woman made because of urinary infection. A, scout film. B, conventional urogram shows normal appearing upper urinary tract. C, tomogram shows mass in right kidney, D, right hypernephroma.
FIG. 8. Urogram of 48-year-old woman made because of hypertension. A, scout film. B, conventional urogram shows normal appearing right kidney. C, tomogram shows mass in right kidney. D, right hypernephroma.
ROUTINE
OF
EXCRETORY UROGRAPHY
7i0 'J_J
FIG. 9. Urogram of 45-year-old woman made because ofhypercalcemia. A, scout film. B, conventional urogram shows normal appearing urinary tract. C, tomogram shows mass in right kidney. D, right hypernephroma.
FIG. 10. Urogram of 56-year-old man made because of prostatism. A, scout film. B, conventional urogram shows normal appearing urinary tract. C, tomogram shows mass in lower pole of right kidney. D, right hypernephroma.
FIG. l 1. Urogram of 45-year-old man made because of urinary calculi. A, scout film. B, conventional urogram shows normal appearing urinary tract. C, tomogram shows mass in lower pole ofleft kidney. D, left hypernephroma.
720