CT

UROGRAPHY
Date: 08.04.2024
 INTRODUCTION
Computed Tomography Urography (CTU) is defined as an abdominal multiphase
CT examination optimized for imaging kidneys, ureter, and bladder, including post-
contrast excretory phase imaging.

Contrast agents used are classified based on:

Ionic vs Non ionic

Osmolality

Iodinated vs non iodinated

Monomer vs Dimer
• The volume of the contrast
material bolus ranges from
100 to 150 ml administered
at a rate of 2 to 4 ml.

• Non ionic contrast agents of

300 mg/ mL is preferred.
 INDICATIONS CONTRAINDICATIONS
 Hematuria.
 Urinary calculus.
 Urinary tract trauma.  Allergy to contrast agents.
 Suspected pelvis or ureteral obstruction.  Renal insufficiency
 Congenital anomalies of kidney and ureter. P regnancy
 Preoperative assessment in kidney donors.
 Postoperative urinary tract anatomy.
 Staging of urothelial malignancy.
 IMAGING PROTOCOL
 There are different acquisition and contrast administration protocols for CT
urography. These include –

1. Triple phase single bolus technique.

2. Dual-phase split bolus technique.

3. Single-phase triple bolus technique.

4. Single-phase Dual-Energy CT
1.TRIPLE PHASE SINGLE BOLUS TECHNIQUE
 The advantages of the acquiring corticomedullary phase are –

1. Precise vascular and perfusion information.

2. Better characterization of renal cortical masses.

3. Detection of hyper vascular metastases.

 However this phase is usually omitted because the small added

benefit does not justify the increased dose.

 The nephrographic phase, also known as the

nephrogenic phase or the renal parenchymal

phase, is a post contrast injection time range in
which there is an optimal enhancement of the
renal parenchyma including the medulla.
 The excretory phase also known as

the urographic phase is a post

contrast injection time range in
which there is an optimal
enhancement of the renal collecting
systems.
 LIMITATIONS OF SINGLE BOLUS
TECHNIQUE
 3/ 4 images are acquired - highest ionizing dose.

 If acquired too early  before the cortex and medulla are uniformly opacified.

 If acquired too late  will detect the early excretion of contrast into the collecting system,

hiding mucosal enhancement within the renal pelvis.

 A timing delay in patients with impaired renal function & in dilatation of the excretory

system.

 an excretory phase performed in a prone position can help the distension and

opacification of the urinary tract.

2.DUAL-PHASE SPLIT BOLUS TECHNIQUE
LIMITATIONS OF SPLIT BOLUS TECHNIQUE

 The main disadvantage of split bolus technique is a lower contribution of

contrast medium to kidney enhancement and to distension and opacification of

the urinary collecting system, which may reduce image quality and sensitivity
for the detection of small renal cell carcinomas and subtle transitional cell
carcinomas.
3. SINGLE PHASE TRIPLE BOLUS TECHNIQUE
 4.SINGLE-PHASE DUAL-ENERGY CT
 This study technique includes following steps –

1. Single bolus (or split bolus) contrast agent injection

2. Single excretory phase (often 80 and 140 kVp)

3. Post processing to generate virtual non contrast enhanced image

 DECT reduces the radiation exposure due to decomposition analysis which generates

virtual non-contrast CT images by separating iodine from soft tissue and water.

 DECT also allows the reduction of the contrast medium dose by using low-energy mono

energetic beams. This is especially useful in patients with a pre-existing renal

impairment and a higher risk of contrast-induced nephropathy.
 OPTIMIZATION OF EXCRETORY
PHASE
 To achieve adequate distension & whole opacification of the urinary tract in a

oral or intravenous hydration before the acquisition.

1. intravenous furosemide administered before the intravenous contrast material.

2. use of abdominal compression devices (belts).

3. prone patient positioning.

REFERENCES:
1 1. Balasubramaniam R, Watson N. Chapman & nakielny’s
.
guide to radiological procedures. 8th ed. Philadelphia, PA:
Elsevier - Health Sciences Division; 2023.
2. Radiological procedures by Bhushan N lakhar
3. Radiopedia