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0:37

Today we are honored to welcome

0:38

Dr. Deborah Baumgarten for a lecture on urothelial cancer and

0:41

beyond CT urography interpretation, including pitfalls.

0:46

Dr. Deborah Baumgarten completed medical school.

0:49

All of her radiology training on Emory University.

0:52

She was on staff at Emory for over 25 years before

0:55

moving to Mayo Clinic in Jacksonville, Florida, in

0:57

2000, where she specializes in abdominal imaging

1:00

with a special interest in ultrasound and GU imaging.

1:03

At the end of the lecture, please join her

1:05

in a Q&A session where she'll address

1:07

questions you may have on today's topic.

1:10

Please remember to use the Q&A feature

1:11

to submit your questions so we can get to

1:13

as many as we can before our time is up.

1:15

With that, we're ready to begin today's lecture.

1:18

Dr. Baumgarten, please take it from here.

1:18

33 00:01:20,820 --> 00:01:21,180 Hi.

1:21

Thanks so much.

1:22

I am honored to give this lecture today,

1:25

and we're going to be talking a bit about CT.

1:28

I don't have any disclosures

1:29

that are relevant to this topic.

1:32

So our learning objectives for today, we're going to

1:35

start talking by talking about exam optimization.

1:39

We'll talk about some things that might

1:40

cause false positives, things that

1:42

you might think are cancer but aren't.

1:45

We'll talk about the best way to review

1:47

images so that you don't miss anything.

1:50

We'll have a few cases that are just for fun.

1:53

We'll talk about some alternative diagnoses

1:55

to urothelial cancer, but then we will

1:57

include some cases of urothelial cancer.

2:00

And as we go along, if you have

2:02

questions, I will try to, to catch them.

2:04

I have my Q&A box open.

2:06

If you're in the chat, I'll have them that open too.

2:08

But I might ask you, you know,

2:10

what do you think about this case?

2:11

And if you want to type in something

2:12

and we'll see if, uh, see who gets it.

2:14

Right.

2:15

So one of the first things you need to

2:17

decide is how are you going to do your exam?

2:19

And there are really two ways to do the exam.

2:21

What is a single bolus?

2:23

And we usually use that for patients that are older than 40.

2:27

It starts with a non-contrast exam.

2:29

You want to see what's there first,

2:31

a baseline. Are there any stones?

2:33

Are there any masses that you might need to characterize?

2:36

Then you administer contrast.

2:39

A hundred to 150 ccs of contrast with a good dose of

2:42

iodine at a good rate, two to four ccs per second.

2:46

You get a nephrographic phase through the kidneys.

2:48

So not really an arterial or a portal

2:51

venous, but slightly later where you get

2:52

relatively uniform enhancement of the kidneys.

2:55

You might start to start to see a little bit of

2:57

excretion, and then you get an excretory phase

3:00

at seven to 10 minutes where you have good, robust

3:03

excretion into the collecting systems and ureters.

3:08

And then you think about repeating areas as needed.

3:11

And we'll talk about that a little bit, too,

3:13

because it does increase the radiation

3:14

dose, but it can be very helpful.

3:19

Sometimes a split bolus is another way of doing things.

3:23

And we usually use this in younger

3:24

patients, those that are less than 40.

3:27

So again, you start with the same non-contrast examination.

3:30

Again, looking for stones or any masses

3:32

that might need characterization.

3:35

You give a small or a moderate dose of

3:37

contrast material as your first bolus.

3:40

You delay between five and 20 minutes.

3:42

So often you'll give this bolus of contrast

3:44

material when the patient is still in the prep area.

3:47

Then you give a second bolus of contrast so that

3:49

the total is not more than a hundred to 150 ccs.

3:53

And you get a single combined nephrographic

3:57

and excretory phase at about a hundred seconds.

3:59

And you can see here we've got uniform enhancement of

4:01

the kidney, but we also have robust, uh, excretion.

4:06

And then again, the more judicious use of repeats,

4:10

because these are usually younger patients.

4:13

Compression, um, is something that was thought to be of use.

4:17

This is a holdover from the days when we used to

4:19

do intravenous urography, and people used to either

4:23

do the exams prone, or they would put a compression

4:25

belt on the patient to try to keep as much contrast

4:28

material in the upper collecting systems, and then

4:31

you would release it and hopefully fill the ureters.

4:34

But that's not shown to be of much use.

4:37

You can think about doing prone imaging,

4:39

but it probably is also not better.

4:41

But one thing you want to think about, and we'll look

4:43

at some cases, is that if you're starting your exam in

4:46

the patient with the patient in the supine position,

4:49

and you have areas of the ureters that are not

4:51

opacified, consider flipping the patient in another

4:54

direction to repeat things.

4:58

So if you also start your exam prone, you might flip

5:00

them supine, and sometimes that will help get contrast

5:03

in other areas of the collecting system and bladder.

5:08

Other things to think about.

5:09

Some people have advocated the use of diuretics or a small

5:12

amount of Lasix, because this tends to decrease the density

5:16

of excreted urine and increases excretion in general.

5:20

So perhaps you'll have less artifact if the urine

5:23

is not as concentrated, and maybe you'll see better.

5:27

But it's kind of logistically difficult,

5:29

depending upon where you practice.

5:31

Because in the United States, at least, a physician has

5:33

to order the Lasix, and then you have to have a nurse

5:36

or a physician to give the Lasix, and it can really

5:38

slow down your turnaround if you're having to do that.

5:41

So we don't tend to give diuretics.

5:44

Hydration, though, is probably useful, and we

5:46

do encourage our patients to come hydrated.

5:49

We can also give them between 750

5:52

and a thousand ccs of oral water.

5:55

And since one cup, about eight ounces, is 240 ccs,

5:59

it's between three and four glasses of water.

6:01

Or, because you have to have an IV started

6:04

already, you can also give a bolus of saline.

6:08

So what do you do about unopacified segments now?

6:12

Normally, it's probably just peristalsis

6:14

if the ureter otherwise looks normal.

6:17

So it's normal caliber.

6:18

It doesn't have any abnormal enhancement on your

6:20

initial nephrographic phase if it was done as a

6:23

single bolus, and you can just ignore it if you are not.

6:28

Um.

6:29

If it's a short segment, um, again, if there's

6:32

nothing else abnormal about the ureter, so for

6:35

example, in this case, when we went through the

6:37

pelvis, the right ureter was really nicely opacified.

6:40

You can see at those dots there.

6:42

But the left ureter was not opacified at all.

6:46

So you can re-scan.

6:47

And in this case, we did actually re-scan, and

6:50

you'll see that the high-density urine is

6:53

anterior now, with lower-density urine posteriorly.

6:56

So we did flip this patient prone in order to re-scan.

7:00

And interestingly, at this point, the right

7:02

ureter was not opacified, but the left was.

7:04

So between the two sets of scans, we were able to piece

7:07

together the ureters and look at them in their entirety.

7:11

You want to base how often you re-scan

7:13

on the age of the patient.

7:15

So younger patients, again, you want to be very careful about

7:18

re-scanning, especially the pelvis in a childbearing-age

7:21

woman, because you just don't want to have that radiation dose.

7:25

So think carefully before you repeat scans and

7:29

certainly don't repeat scans too many times.

7:33

Layering is also sometimes an issue, especially in

7:36

dilated segments of the renal pelvis or the bladder.

7:40

As you can tell, in this case, we

7:42

have a dilated system. In order to try to

7:46

decrease the problem in the bladder,

7:48

we do have patients try to void immediately

7:50

prior to giving them IV contrast.

7:53

That will help with that segment.

7:55

And it might, if you have some reflux or back

7:58

pressure on the collecting system.

8:01

If the bladder is full and you have dilated

8:04

collecting systems because of that, voiding will help.

8:07

You can have the patient walk around prior to scanning

8:10

them, especially if you do that split bolus, to try

8:12

to mix that contrast around, or rotate the patient

8:16

a couple of times on the table to try to mix things.

8:19

And you also can narrow your window

8:20

to increase conspicuity of things.

8:23

So this is how this patient was originally scanned.

8:25

They were scanned prone to begin with, and you can

8:27

see there's layering of higher-density contrast in the

8:30

collecting system and this kind of mildly dilated ureter.

8:35

And this was this patient's bladder.

8:37

You can see that we also scanned the patient prone.

8:40

This is an indication of the gantry here.

8:42

This little line there was the patient was

8:44

laying on the gantry. The higher-density urine

8:47

with contrast in it is more dependent.

8:50

And then here is a lesion that we can kind of barely

8:53

see in this patient because of the layering effect.

8:57

So scanning this patient supine as a repeat, having

9:01

them rotate a few times on the table and then scanning

9:03

them will help us also be seen a little bit more easily.

9:08

So here's another patient that was scanned originally

9:11

prone, and there's very dilute urine in the bladder, which

9:14

was pretty distended before we gave contrast material.

9:18

Then we look in, like, you know, what's going on here?

9:20

This is the area of the distal left ureter, and

9:23

it's dilated, but we have very faint opacification,

9:27

maybe even a little bit of layering here.

9:29

It's very hard to tell if there's any

9:30

soft tissue or just poor opacification.

9:34

So we waited a little while and then repeated

9:36

this patient supine, and you can see there's

9:39

actually a very large filling defect.

9:42

This ureter, which turned out to be a large

9:44

urothelial carcinoma, which is much more easily

9:47

seen when we repeated this patient supine.

9:51

This is the same patient again,

9:53

scanned prone to begin with.

9:55

So we have high-density material dependently, and

9:59

when we turned the patient supine and repeated it,

10:02

the higher density again falls more dependently.

10:05

But you can see that there are actually two filling

10:07

defects within the collecting system that were unable

10:12

to be seen at all on the original prone because

10:15

they're in areas where the urine is not opacified.

10:19

So repeating in a different, uh, rotation or different

10:23

orientation is sometimes very helpful, again, especially for

10:27

these areas that are very dilated and not well opacified.

10:33

So once you've got what you think are the

10:34

best images, how are you going to review

10:37

the images to make them more optimized?

10:40

So the first thing is if you're doing a single bolus,

10:43

you have to look very carefully for abnormal enhancement

10:46

during that initial nephrographic or venous phase.

10:50

And you can see here, this is the ureter

10:52

here, but it's dilated, and it's got some areas

10:56

here that are enhancing along the side here.

11:00

And this is what it looks like on the delayed

11:03

phase, where you can see that filling defect in

11:05

the area where there was abnormal enhancement.

11:08

So this is just another check.

11:10

So if this segment were not opacified when we

11:13

did the delays, this might be a good candidate

11:16

to have repeat imaging through this region.

11:19

Maybe prone if you had scanned them supine to begin with

11:22

to confirm that there is indeed a filling defect there.

11:27

The other thing that you want to do is review

11:29

your delayed images on a bone window.

11:32

So here we have images here that are on a regular

11:36

soft tissue window, an axial and a coronal here.

11:41

And when we put this on a bone window, you can see

11:43

that there's a very small filling defect in the

11:46

collecting system that you would not otherwise notice.

11:49

And these are exactly the same images, just

11:51

windowed differently in order to bring out those

11:54

little filling defects that might be very

11:56

small urothelial carcinomas, although there are

11:59

other differentials for small filling defects.

12:02

But you have to recognize it first

12:04

before you can work it up any further.

12:08

So these windows, this contrast is too bright

12:11

to be able to see these small filling defects.

12:15

Reconstructions can also be helpful.

12:18

So, for example, some 3D reconstructions, you can see that

12:21

there's irregularity of the ureter, and it gives you an

12:24

idea better than the axial phase or a coronal, where the

12:29

ureter may not be in a single plane on a single slice.

12:32

It gives you a better idea of the length of the abnormality

12:35

that the urologist is going to have to deal with,

12:40

and this is what that looked like on a retrograde

12:42

study in order for them to get a biopsy.

12:45

So

12:50

you also want to make sure that you remember to

12:52

go back and look at your non-contrast images,

12:54

because some filling defects are just small stones.

12:58

So, for example, here's a soft tissue

13:00

window through the left kidney.

13:02

Here's that same on a bone window.

13:04

And boy, it looks like there's a large

13:06

filling defect in the middle of that calyx.

13:09

But when I go back and look at the non-contrast

13:12

images, there's a stone there, and on the

13:15

bone window, you can see that the stone, for

13:17

whatever reason, had a relatively lucent core.

13:20

So this mimicked a filling defect

13:22

that was just a funny-looking stone.

13:25

So be careful not to overcall

13:27

something that was just a stone.

13:32

Other things that can cause false

13:33

positives, prominent papillae.

13:35

So these are multiple and symmetric.

13:38

So they're going to be at the kind of the root

13:40

of all the different calyces, they're cup-like shaped.

13:44

And that's pretty much where they are.

13:45

And you can see them in multiple places.

13:47

And they're symmetric from one side

13:49

to the other, generally speaking.

13:51

So you can call those if they are just in the

13:55

middle like that and cause that little C shape.

13:59

Ureteral tortuosity can also be an issue.

14:02

So here's a ureter that's very tortuous, and

14:06

on these reconstructions, it almost looks like

14:08

there's multiple small filling defects in here.

14:11

So one thing that you can do is scroll carefully.

14:14

So you can go up and down on the axials to make

14:17

sure that you're not really seeing anything.

14:20

You can use other planes.

14:21

Again, like I said, do this coronal

14:23

reconstruction to try to see that.

14:26

But the other thing you can do is repeat the patient in

14:29

expiration so that when you think about it, the ureter has

14:34

to be long enough so that when your diaphragms are as high

14:37

as they can be in expiration, you're not stretching them.

14:40

And when you inspire, the kidneys go down,

14:43

and the ureter kind of becomes redundant.

14:46

So by repeating in expiration or even just

14:48

scanning patients in expiration to begin

14:51

with, you can get rid of that tortuosity.

14:54

Now it is harder for patients to hold their breath

14:57

when you tell them to breathe out first, which is

15:00

probably why we do most of our studies in inspiration,

15:04

but it can be something, another tool in your arsenal.

15:08

I've got a question here about papillary necrosis,

15:11

and I've got some cases of that, so hopefully the

15:13

question will be answered when I get to that part.

15:17

There are also probably false negatives,

15:19

but we don't know what we miss,

15:21

because no imaging is a hundred percent sensitive.

15:24

So if a patient has, for example, atypical cells in

15:27

their urine and you see nothing on your CT urogram,

15:31

and they've had a cystoscopy and there's nothing

15:33

in the bladder, you just have to be very careful to

15:36

follow up those patients that have a high suspicion.

15:39

Maybe you didn't opacify every segment of the ureters

15:42

perfectly, or you couldn't see something very small.

15:45

So those patients just need careful follow-up.

15:49

So let's look at some cases.

15:52

But before we get to our usual case review,

15:55

I thought I would do a couple of fun things here.

15:58

So this is what we used to do in order to make diagnoses,

16:01

and still, we still do retrogrades today, but not probably

16:04

as great as we used to, or not as often as we used to.

16:09

So this is a patient here on a retrograde study.

16:13

Does anybody know what this sign is called

16:15

when you have this kind of dilated ureter

16:19

below the level of a filling defect?

16:22

Does anybody want to type in what they think it is?

16:28

Goblet sign.

16:29

Excellent, excellent.

16:33

That's what this would look like now.

16:35

So here is a coronal reconstruction here.

16:38

There's a filling defect in our

16:39

ureter and that same goblet sign.

16:42

So what we learned on CT urography, excuse me, regular

16:46

urography can certainly be applied to CT urography.

16:50

So we're going to do a few of these sorts of cases.

16:53

So here we go.

16:53

We have this, um, unusual configuration of the distal ureter

16:57

here, and the bladder looks like it's kind of off in space.

17:01

So does anybody know what this

17:02

sign is called?

17:10

This one's a little harder, I guess.

17:11

Well, it's shaped like a J or a fishhook, and that's

17:15

what that was called, a fishhook sign or J-hook sign.

17:21

And this is what this looks like on the CT urogram.

17:25

Now the ureters are sort of pushed up because the prostate

17:30

is enormous in this patient, and that's

17:32

what's pushing this bladder up as well.

17:34

So a large prostate can cause the

17:36

distal ureters to form this shape.

17:40

All right, somebody said this one for the

17:42

last case, so I'll say they were

17:44

probably prescient in terms of writing this down.

17:47

Does anybody know what these were called?

17:52

Yes.

17:52

The cobra sign or snakehead sign?

17:54

Cobra head sign.

17:55

Excellent.

17:56

And this is an indication of a ureterocele,

17:59

so it's a distal dilatation of the ureter.

18:02

And this is what this looks like on a CT urogram.

18:04

Here.

18:04

We've got concentrated urine in these, um, ureteroceles.

18:08

There's probably a little stone in this one, and

18:11

this is what that looked like on a reconstruction.

18:15

All right,

18:15

how about this?

18:16

What's going on in this patient?

18:26

Duplex.

18:26

Right, exactly.

18:27

This is a partially duplicated system here on the

18:30

right. We only have one ureter inserting into the

18:32

bladder here, and this is what this might look like.

18:36

Now with some fancy reconstructions, we can

18:38

see we have a duplicated system to this point,

18:40

and this one is duplicated a little bit lower.

18:43

Excellent.

18:44

How about this?

18:45

This is a retrograde study,

18:52

also duplex and a Y-lily, right?

18:55

Or the drooping lily sign.

18:56

This was an indication that there was an upper

18:58

pole moiety that doesn't have the same ureter

19:01

that's dilated and causing this to droop.

19:06

And that's what it would look like on this case.

19:08

And there was an upper pole cystic

19:10

structure, a system that was completely

19:13

obstructed up here and pushing this down.

19:16

Great.

19:17

This is, I think, the final one.

19:19

I—nope, I have a couple more of these.

19:21

So here we have this little paintbrush

19:23

looking stuff here on an old IV urogram.

19:30

Does anybody know what this would be?

19:34

Somebody said papillary necrosis.

19:37

Medullary sponge actually is the correct answer.

19:39

Or sometimes we used to see this with, um, non-

19:42

ionic contrast when we first started using it.

19:45

You'd see that a little bit more.

19:46

But medullary sponge is a good thought.

19:48

And this is what it looks like on an axial

19:51

image and some coronal reconstructions.

19:53

This patient also has partially

19:54

duplicated, or bifid, renal pelvis.

19:59

All right, how about this one?

20:02

You can see that there's a ureter here and a

20:05

ureter here, but they crossed to the other side.

20:09

It's not a horseshoe, but close, crossed, fused.

20:13

Excellent.

20:15

That's what this looks like.

20:16

Here's a cross-fused kidney, and

20:17

this is just the bottom part.

20:19

And here's one ureter and the other ureter.

20:22

You've got to remember in these cases the kidney crosses,

20:24

but the ureter is in its normal insertion place.

20:31

And this one, I want you to focus

20:32

on the course of this ureter.

20:37

And here I'll just show you what it looks like now.

20:40

And this one is helpful because this has a structure here.

20:43

Yes, this is a retro—it’s not retroperitoneal fibrosis.

20:48

This is a retrocaval ureter.

20:50

Excellent.

20:50

Somebody got that answer.

20:52

So this ureter is going behind the cava.

20:54

The cava is right here, or this faint line here.

20:58

So this is what it used to look like, and

21:00

what we can see now—I’ll clue you in.

21:04

There's some couple of small filling

21:06

defects along this renal pelvis here.

21:09

Multiple little round, smooth filling defects.

21:18

455 00:21:20,940 --> 00:21:26,520 And this is what it looks like on our reconstructions.

21:25

457 00:21:26,520 --> 00:21:28,600 Now I've gotten a couple of answers.

21:29

Diverticula or papilla.

21:29

Yeah.

21:30

Cystitis glandularis or ureteritis cystica.

21:34

So these are just these little cystic spaces in

21:36

the, just below the mucosa, and they're benign.

21:39

But you don't want to mistake these for

21:42

urothelial carcinoma in this case here.

21:48

So we've got this sort of lucent-ish

21:52

compared to the rest of the kidney.

21:55

It's a claw sign.

21:56

Correct.

21:57

So it's just a cyst.

22:00

And we used to have to make the diagnosis,

22:02

in fact, there's multiple of them here, used

22:04

to have to make the diagnosis on a urogram.

22:06

Much easier to see them on a CT.

22:08

These things.

22:09

All right, so let's talk a little bit

22:12

about UCC, but talk about hematuria first

22:15

that is not urothelial carcinoma.

22:19

So somebody brought up this diagnosis before,

22:21

and hopefully this will answer the question.

22:25

Does anybody know what this case is?

22:33

Yes.

22:34

Papillary necrosis.

22:35

Exactly.

22:36

So what you see here, instead of that normal

22:38

nice C shape of this papilla, it's more T-shaped

22:43

or like a ball on a tee, a golf tee.

22:46

And that's the little ball.

22:48

And that's the tee, and that's what

22:50

this looks like after the papilla has sloughed.

22:53

And then you might also see a filling defect,

22:55

although we don't tend to see the filling defects

22:57

as often as we see the little golf ball on the tee.

23:01

And you can see that this has happened in a couple of

23:03

different papillae, in this case, at least two.

23:07

There's lots of risk factors for papillary necrosis.

23:10

So you can go back to the patient's chart and

23:12

see what medications they're taking, if they have

23:14

any other risk factors for papillary necrosis,

23:16

and that'll help you make the diagnosis as

23:18

well, or at least feel more confident about it.

23:21

But it's really more the shape of this

23:22

papilla and the little dot of contrast

23:25

that's really helpful.

23:29

And this is just another case here where we can see that

23:32

ball on the tee and another case of papillary necrosis.

23:39

All right, this is the same patient.

23:43

507 00:23:46,500 --> 00:23:48,240 Actually, um, actually no, I take that back.

23:48

This is a different patient.

23:49

This is a bladder we're looking at.

23:50

The patient was laying prone when we took

23:54

this image, because the concentrated contrast.

23:57

Does anybody know what's going on here?

24:04

There's a filling defect here.

24:07

So we went back and looked at our original

24:10

non-contrast scan, which in this case was done supine.

24:16

And you can see that there's a very dense area here that

24:20

is not in the same location, but now is just floating here.

24:23

So

24:27

Yes, this is a blood clot or hematoma, so you've

24:30

got to be careful if you see something like this.

24:32

Again, changing the patient position on the

24:34

non-post-contrast scan will help, because this—

24:37

if you turn the patient supine,

24:38

it will fall more dependently.

24:40

Or again, reviewing your previous

24:42

non-contrast images is also very helpful.

24:45

So that's just a blood clot.

24:49

All right, how about this patient?

24:51

So I have the initial scan, and then

24:53

I have the delayed images here.

24:58

So I'll draw your attention here.

25:01

This renal pelvis has got some inflammation around it.

25:04

There's abnormal enhancement.

25:07

It's a little bit prominent.

25:09

And on the delays, what you're

25:10

seeing is just some thickening.

25:13

Yes, pyelitis.

25:14

Excellent.

25:15

So there's a couple things you can do

25:16

that'll help you cinch this diagnosis.

25:18

One, you can check the urine.

25:20

There might be inflammatory cells, or there might

25:24

be, um, white blood cells, you know, bacteria.

25:28

But it can also be a sterile pyelitis, just an irritation.

25:31

And this patient happened to have had a stent

25:33

removed recently, so their urine was clean, but they

25:36

were still irritated from having a stent in place.

25:39

Good.

25:42

So here we've just got delays through the pelvis.

25:44

I can see the ureters here.

25:47

There's some unopacified urine that's in this

25:50

case since the patient was originally scanned

25:52

prone. The more dense urine is more

25:56

dependent, but there's some thickening here.

26:00

Kind of diffuse.

26:02

So somebody saying cystitis, excellent,

26:04

because I've said this is stuff that we want to

26:06

think about that's not urothelial cancer.

26:09

But clearly, when you have asymmetric bladder thickening, the

26:11

first thing you probably think about is urothelial cancer.

26:15

In this case, it might be very helpful if we

26:16

had the initial scans where we saw if this

26:19

looked like it was enhancing abnormally at all.

26:22

But this was biopsied multiple times because it

26:25

was persistent, and this was just focal cystitis.

26:29

So that can happen as well.

26:32

All right.

26:32

Well, hematuria is not the only thing

26:34

that we might use a CT urogram for.

26:37

Sometimes we're doing this for a patient who has

26:39

hydronephrosis, maybe discovered on an ultrasound or

26:43

maybe even on a non-contrast CT for flank pain, and

26:46

we want to know why they might have hydronephrosis.

26:49

But let's think of some things

26:51

that it's not urothelial cancer.

26:53

So here we have a patient.

26:55

I'm showing you the excretory images.

26:57

Again, this patient was scanned prone.

26:58

You can see the gantry marker here, and

27:01

the more dependent urine is anteriorly.

27:05

We have a left kidney that has hydronephrosis.

27:07

We see hydroureter,

27:14

and I've got a reconstruction here as well.

27:16

And as we follow that ureter down, there seems to be

27:20

something going on here and here on the reconstruction.

27:25

It's not ectopic that somebody suggested.

27:29

There is not actually a stone

27:31

there, but there is a stricture.

27:32

Excellent.

27:33

So there are a lot of reasons why

27:34

patients might have strictures.

27:36

This patient could have had instrumentation done, so

27:38

they could have had a stent in place, or could have had

27:41

a retrograde study where they stuck a scope in there.

27:44

The patient may have had surgery recently, and there

27:46

was a surgical mishap that caused a stricture.

27:49

Or some other trauma.

27:51

In this case, the patient had had surgery,

27:53

and this was a postsurgical stricture.

27:56

So in these cases, they can try to do

27:59

a ureteral reimplantation if there's still

28:01

enough residual function in the left kidney.

28:04

In this case, there's clearly plenty of parenchyma here,

28:07

and you'd want to do anything you could to save this kidney.

28:10

So they would resect the part that was

28:12

narrowed and just reimplant the ureter.

28:15

Good.

28:17

How about this one?

28:19

So

28:19

clearly we have a left side that's got a dilated system,

28:30

UPJ obstruction.

28:31

Excellent.

28:33

So there are two reasons why someone

28:34

might have a UPJ obstruction.

28:36

One would be a crossing vessel, and the

28:38

other is just an intrinsic muscular issue.

28:42

So in this case, you can see that

28:44

there's a little vessel there.

28:46

You can see it looping around here.

28:48

So this was from a crossing vessel.

28:52

And this is the same patient on another, um, projection here.

28:55

And again, you can see that crossing vessel

28:57

across the UPJ, and that's the ureter coming

29:00

down that is not obstructed below that level.

29:06

And here's one again, very clearly.

29:08

You can see that crossing vessel, and you

29:11

can see where it's kinking that ureteropelvic

29:13

junction, right where that vessel is.

29:16

You can see it there as well.

29:19

So someone's asking what my protocol

29:21

is for UPJ assessment, CT, and—

29:24

It's the normal CT urogram, but I prefer to do it with a

29:28

single bolus so that we can see all the vascular structures,

29:31

and then we can get a sense of the excretion of the kidney.

29:34

That also helps you decide if there's really

29:36

a stricture, a functional obstruction, if

29:39

the kidney is delayed in its enhancement at all

29:42

compared to the other side, that can be helpful too.

29:44

But we tend to just do a routine CT urogram protocol.

29:49

Someone else is asking about an extrarenal pelvis.

29:52

In that case, there's usually more smooth

29:54

tapering between the ureter and the pelvis.

29:57

There's not an abrupt cutoff between the two.

30:01

Um, sometimes it's just hard to tell.

30:03

But the other thing, again, is looking at the renal function.

30:05

If the function is symmetric with the

30:07

opposite side, it's normally an extrarenal

30:09

pelvis, or can be an extrarenal pelvis.

30:12

So again, this was a UPJ with a crossing vessel.

30:16

This is a UPJ that did not have a crossing vessel.

30:19

So this just had a very tight intrinsic stricture

30:22

between the pelvis and the dilated ureter.

30:27

So somebody else asked about doing an

30:28

angio phase to rule out a crossing vessel.

30:31

It depends.

30:32

I mean, I think if there's a really strong

30:34

pretest probability that you have a crossing

30:36

vessel, and on a routine scan or something else

30:39

where you've looked for it, it wasn't obvious.

30:42

Adding an extra arterial phase just through the

30:44

kidneys to look for that is probably not a bad idea.

30:49

It's just often we find them incidentally.

30:51

But I don't disagree with the

30:53

thought that trying to optimize something one

30:56

time through the patient is probably good.

30:59

So you can, if you want, add an arterial phase,

31:02

but I wouldn't do it through the whole body.

31:04

I would just focus on the kidneys in that case.

31:07

But you'd have to have a pretty strong pretest probability.

31:12

Another reason why one might do a CT urogram

31:14

is recurrent urinary tract infections.

31:17

And so you want to look for anything

31:18

that might be a source of stasis,

31:21

because stasis is something that

31:22

can cause bacteria to thrive.

31:26

So does anybody know what we're

31:27

looking at in this particular case?

31:29

And again, this patient was scanned prone.

31:31

So the denser urine is more dependent, which in

31:34

this case, since I flipped the patient, is anterior.

31:40

A calyceal diverticulum.

31:41

Excellent.

31:41

In this case, we see this structure here

31:47

that is filling with contrast material at the

31:49

same rate as it's filling the collecting system.

31:52

So this is another source of stasis.

31:54

This is a source of stasis, or can be.

31:56

There can be stones in these things.

31:57

They may have debris in them.

31:59

So this is a good source of a urinary tract

32:02

infection or a repeated urinary tract infection.

32:04

If this becomes infected and they can't clear that.

32:09

It might mimic a cyst on a

32:11

non-contrast scan or an ultrasound.

32:15

So that's again a calyceal diverticulum.

32:19

And here's another one here, another calyceal diverticulum.

32:25

But if we look at the non-contrast study first,

32:27

you can see that this one had some stones in it.

32:30

So yes, absolutely.

32:31

You can see or suggest there might be a filling

32:33

defect in there, and it indeed was a stone.

32:39

How about in this case,

32:50

before

32:50

I, let me answer this question.

32:52

Do I have a standard measurement for when I don't say pelvic

32:54

ectasis, extrarenal pelvis, and say hydra or UPJ obstruction?

32:59

I'd have to say that I probably

33:00

gestalt it more than anything.

33:02

I kind of look at whether or not there's any

33:05

renal parenchymal loss.

33:07

That might imply that somebody's

33:08

had a long time ex, um, obstruction.

33:11

I look at whether or not the function of

33:14

that kidney is as robust as the opposite

33:16

side, so I'm looking at other things as well.

33:19

So back to this case.

33:20

So yes, exactly, a urethral diverticulum.

33:23

So this is a female patient.

33:24

This is the vagina here.

33:26

We've got our ureters coming down, and then below the

33:29

bladder around the urethra, and you can see it here, there's

33:34

a low-density structure that is a urethral diverticulum.

33:40

So these can also present with, uh, dyspareunia.

33:44

They can present with a palpable

33:45

lesion in the vaginal introitus.

33:48

They can present with dribbling or

33:49

what's thought to be incontinence.

33:51

So there are a variety of presentations for these.

33:55

Um, we describe them like the face of

33:57

a clock, how far around does this go?

33:59

And this one is pretty much circumferential.

34:02

So it's, you know, noon to midnight in this particular case.

34:05

So this is a particularly large one.

34:07

You can have stones in these as well.

34:09

So that's a urethral diverticulum.

34:13

All right, how about this patient?

34:15

We're scanning the pelvis.

34:16

This is at the level of her hips or acetabula.

34:19

We're going down, we're at the pubis.

34:21

We're below the pubis and continuing down.

34:25

Yes, this is a particularly large cystocele.

34:28

And when we, the tech astutely realized

34:31

they had not gone through the whole bladder and

34:33

had added on some additional imaging, which is

34:35

why this is very blurry on the reconstruction.

34:38

Because the bladder is trying to exit

34:40

the body in this case, and this woman.

34:42

So she's got some pretty significant pelvic

34:45

floor laxity, and you can imagine how difficult it

34:48

must be for her to empty her bladder when part

34:51

of it is stuck in the introitus like this.

34:53

So this can be another source of urinary tract

34:56

infections that don't clear or are recurrent.

35:01

And this is another case of a cystocele.

35:03

So here we are just on the original phase,

35:06

and you can see how low the bladder neck is.

35:09

And then this is after we filled the

35:10

bladder on a coronal, how low it is.

35:13

So again, another cystocele.

35:16

And then I wanted to show this one just because

35:19

you can see, look at where the ureters are going.

35:22

This ureter is almost out the introitus as well.

35:25

So again, this is going to be difficult for this

35:27

patient to empty well, and in fact, the ureter is

35:31

a little bit dilated above that level on this side,

35:35

because of where the ureter had to go to enter the bladder.

35:39

And this is again, look at that ureter

35:41

coming down, and here, I don't know, there's a

35:44

little bit of fullness to both collecting systems.

35:46

Again, probably because of where the ureters

35:49

are inserted, but there's a good bit of

35:51

parenchyma here, so I'm not sure there's actually

35:54

functionally obstruction, just some fullness.

36:00

All right, let's have some miscellaneous cases here.

36:03

So here we have a woman.

36:05

Here's her vagina.

36:06

This is her bladder.

36:07

It's pretty decompressed.

36:09

Not entirely sure where this air is on the

36:12

single slice, but it's a little suspicious.

36:15

And then we gave contrast material.

36:19

It's leaking.

36:20

So yes, we have a fistula, and in this

36:22

case, yes, it's going to the vagina.

36:24

So there's probably air, there is air in the bladder, because

36:27

the vagina clearly is in contact with the outside world.

36:31

So you can get air that refluxes into the vagina

36:33

and then can get into the bladder as well.

36:36

Um, this is often a surgical mishap.

36:38

Somebody who's had a hysterectomy would be not an

36:41

unusual presentation for a vesicovaginal fistula.

36:45

So that might be something that you are

36:47

easily able to diagnose on a CT urogram.

36:51

In these cases, you would not want to scan the

36:54

patient prone, because you really want the urine,

36:58

the heavy urine, to be posterior so that you

37:01

can see that communication with the vagina.

37:03

So in these cases, there would be no point

37:05

in turning the patient on their stomach.

37:11

Okay.

37:11

How about this case?

37:15

So we can see the ureters are coming down

37:17

here, and you can see where both ureters are

37:19

inserting and actually excreting a little bit.

37:22

But then we've got this funny thing here that's

37:24

the same density or similar density to the urine

37:29

that's opacified.

37:34

Diverticulum, yes, it's a bladder diverticulum, and in

37:37

this case you can see that there's some high density in

37:41

there, which was there actually on a pre-contrast study.

37:44

So there was some calcification in there.

37:46

We're also not uniformly enhancing here.

37:49

There's some areas here that are not as well opacified.

37:52

This turned out to be a urothelial cancer

37:54

within a diverticulum, which can happen.

37:58

So that is an interesting miscellaneous case.

38:04

And I'll

38:04

show you.

38:05

Here's a second one.

38:06

So here's the non-contrast.

38:11

Here's our original phase.

38:13

This

38:13

is a bladder.

38:14

This is not the ureter.

38:16

So here we have an enhancing lesion, and here we have

38:19

it surrounded by some partially opacified urine.

38:24

So this is another diverticulum.

38:26

This one turned out to be a squamous cell carcinoma

38:28

within this diverticulum, and we could have

38:31

a whole lecture on staging of bladder cancer.

38:35

And what do you do when they're in a diverticulum?

38:37

Just suffice it to say that because the

38:39

diverticula don't have the muscular layer, um,

38:43

they're more easily outside of the confines of

38:46

the diverticulum than they are in the bladder.

38:49

And you can't use muscular invasion as

38:52

a part of the staging system for these.

38:54

So it's a little bit different.

38:55

But if there is no other lesion, you can just resect

38:59

the diverticulum and not the bladder often in these

39:02

cases and leave the patient with a bladder that works.

39:08

Okay, so here's our original phase.

39:11

Here is an axial and a sagittal,

39:14

and then here are the delays.

39:17

And this is a little odd-looking near

39:20

where the ureters would insert.

39:22

I don't actually see the ureters

39:23

very well on this delayed phase.

39:30

Someone says endometrioma.

39:31

I kind of like that answer.

39:33

This is an older person, though.

39:36

This was a spindle cell tumor, and I think it's

39:39

really hard in this case to decide what layer of

39:41

the bladder wall this is in, but here it is here on

39:44

this ultrasound, and you can see that it's actually

39:48

submucosal, which is much harder to see on the CT.

39:52

So that's why this was suggested to be a spindle cell tumor.

39:55

You can also think about something like a leiomyoma,

39:58

a nerve sheath tumor or something like that.

40:00

These are unusual.

40:02

Certainly would have to have a cystoscopy, because

40:05

this differential would be urothelial carcinoma first.

40:09

But then when the urologist was in there, they

40:12

would see intact mucosa with a bulge and just

40:15

have to do a deeper biopsy to make a diagnosis.

40:21

How about this case?

40:22

So

40:26

we can see that the abnormality

40:28

is mostly at the bladder dome.

40:30

Yeah, so we think about urachal abnormalities,

40:34

but this is a little bit more irregular,

40:36

and this patient did present with hematuria.

40:41

So yes, urachal adenocarcinoma was, in this case, the answer.

40:45

It could still be a urothelial.

40:46

We certainly can get urothelial cancers at the bladder

40:49

dome, but in this case, the location suggests that it

40:53

might be something else, especially since we can see

40:55

that there's a little urachal diverticulum left here, too.

40:59

So this does have implications when you have

41:01

a different cell type than urothelial cancer.

41:04

When you have adenocarcinomas, it's not going to

41:07

occur elsewhere in the collecting system or the

41:10

ureters, because this is very unique to the urachus.

41:14

So the follow-up of these patients is very different.

41:16

You don't have to worry about filling defects elsewhere.

41:19

You're not looking for multifocal urothelial cancer.

41:22

Again, it's confined to that area.

41:27

So again, this was a urachal.

41:29

All right, let's show a few cases of urothelial cancer.

41:32

Clearly, I'm not going to have you yell out

41:34

the answers here, but this is a patient. We had

41:37

very nice opacification of her bladder, because

41:40

she rolled around for us before we took images.

41:42

We can see her ureters here, but clearly,

41:45

in her bladder, she has multiple polypoid

41:48

lesions that are sticking off the wall.

41:51

So this is a multifocal cancer, and this is cancer.

41:59

Here's another patient where we start again

42:01

with our non-contrast scan, and we can see that

42:06

there is a stone in the collecting system here.

42:09

But we can also see that there's a

42:11

bunch of little speckled calcifications.

42:13

And you might think, well, this

42:14

is just a cluster of small stones.

42:17

But you also have to remember that urothelial carcinoma can

42:20

also calcify, and when it's this kind of speckled look like

42:24

this, when they're clustered, you have to think about that.

42:27

So anytime you do a non-contrast CT for a stone protocol,

42:31

if they're small and round and they're in the collecting

42:33

system and they're, they're most likely going to be stones.

42:37

But if you ever see this little speckled appearance

42:40

or linear calcifications, think about something else.

42:44

This is not in the right location for nephrocalcinosis

42:47

because it's not in the medullary or cortical regions.

42:49

This is in a calyx.

42:52

So this is the same patient on the excretory imaging,

42:55

and you can see there's actually a lot of soft

42:57

tissue associated with those speckled calcifications

43:00

and a much larger filling defect that we can see

43:03

in this area here of wall thickening, and here too.

43:07

So this was a fairly large

43:09

urothelial carcinoma in this patient.

43:11

So again, if you see linear calcification and you can't

43:14

associate it with an artery, for example, when you're

43:17

definitely sure it's in the collecting system, or if

43:20

you see even bladder wall calcification, one of the

43:23

things you need to think about is urothelial cancer.

43:26

Again, there is a differential for

43:27

wall calcification in the bladder.

43:29

You know, schistosomiasis in some parts of the

43:31

world, maybe old TB, something like that.

43:34

But do think about urothelial cancer as well.

43:43

All right, how about this case?

43:44

We will review.

43:45

So here we can see that the right ureter is filled.

43:50

Then we see that it's not filled.

43:52

There's a filling defect, there's a

43:53

filling defect, there's a filling defect.

43:56

Then it's kind of normal caliber.

44:02

So this is another way that you might see a urothelial

44:04

carcinoma as a filling defect that expands the ureter

44:09

and then the ureter is more normal below that level.

44:14

Or how about this case?

44:17

There's a tiny little area that looks like it might

44:20

be denser than the rest of the urine, but the,

44:22

sorry, the rest of the, uh, collecting system.

44:25

But you've got to be a little careful

44:26

if you've got some excretion already.

44:29

So here we are in the excretory phase, and

44:32

there's clearly a little filling defect there,

44:37

and sometimes our reconstructions are just kind of fun.

44:40

You can see that little dimple there.

44:44

So we found one, but remember these can be multiple.

44:49

So this is the same patient, and this

44:53

ureter is not well opacified here.

44:56

In fact, it looks like there's some soft tissue in it.

45:00

And here we are in the excretory phase, and you can

45:03

clearly see that there's a filling defect in that ureter.

45:06

And this is what the reconstruction looked like.

45:09

So this was multifocal urothelial carcinoma.

45:12

So there was one up in the collecting

45:13

system, and there was also one in the ureter.

45:16

So don't be satisfied when you found one.

45:18

Look really carefully for other parts.

45:22

So someone was asking me, how do I differentiate

45:25

the area that looked like it was just

45:27

expanded and then went down to norm to normal?

45:30

How do I differentiate that from peristalsis?

45:34

Peristalsis itself should not dilate the ureter where

45:38

you have the area of that looks like it's un-opacified.

45:40

If it's peristalsis, it would normally

45:42

be collapsed in that area, not dilated.

45:44

So I get a little more worried when I see

45:46

an un-opacified segment that's also larger.

45:50

So that's one way to think about it.

45:52

The other is, look at all of your images.

45:55

If you have a nephrographic phase, look

45:58

back at that area to see if there was

46:00

some abnormal enhancement in that region.

46:02

'Cause that can also help you.

46:04

Or was that region completely collapsed in

46:06

normal caliber on the pre, uh, excretory phase?

46:11

That could also be helpful.

46:16

All right, let's look at a few more cases here.

46:26

So I'm coming along here, and I've got

46:30

some faint opacification of my ureter.

46:33

Then something looks a little denser, and

46:36

then I've got pH opacification of my ureter.

46:40

So what do you think might be going on here?

46:47

Yeah, there's a stone,

46:49

but the stone is not completely obstructing the ureter

46:52

because I'm able to get contrast below that level.

46:55

So this would be very helpful, again, to

46:57

look back at your non-contrast images.

46:59

Or in this case, we did a reconstruction, and you

47:01

can see those two little stones are just sitting

47:03

there, and there's a opacification above that level,

47:06

and then there is a ification below that level.

47:09

So yes, those were just non-obstructing

47:11

or in completely obstructing stones.

47:16

All right.

47:16

1004 00:47:18,254 --> 00:47:19,395 How about this case?

47:28

Clearly, I'm looking at the structure on the left kidney.

47:32

So someone's asking, maybe an old infarction.

47:37

Well, clearly we have very little, if any, parenchyma here,

47:45

the calculus causing ectasis.

47:46

So I'd be pretty, pretty extreme.

47:50

If you think about it though, if you look at how much

47:53

kidney there is here and how much collecting system

47:55

there is here, an obstructed moiety is a really good idea.

47:58

So somebody got it right?

48:01

Yes.

48:01

So this is kind of keeping its renal form

48:04

shape, but we're missing part of the kidney, and

48:06

there's very much, it's very much blunted here.

48:09

So this was a partially, at least partially duplicated

48:12

system where sometime way in the past, this is completely

48:16

obstructed and just filled with urine, old urine.

48:22

Okay.

48:23

How about this?

48:27

Not a hard case necessarily.

48:28

Just kind of cute, I thought.

48:31

So this is pretty wide mouth here.

48:33

We're filling,

48:37

yeah, this is just a, a large diverticulum,

48:39

and someone said Hutch diverticulum.

48:40

And it probably is true because there's

48:42

the ureters coming right near there.

48:44

So Hutch diverticula are near the ureteral

48:46

insertion, which is probably coming in right

48:48

about here, given where I see the other one.

48:51

So on another window we can see that actually

48:54

there's urine that's going back and forth.

48:55

So this diverticulum is actually, the urine is coming

48:59

back into the bladder, which you can actually see

49:02

really nicely on this patient's ultrasound as a,

49:05

a jet of color effect because the urine will empty

49:09

intermittently from the diverticulum back into the bladder.

49:13

So when you have very large diverticula, patients

49:16

empty, and then they feel like they have to

49:18

go again pretty quickly sometimes because the

49:20

diverticulum will then empty back into the

49:22

bladder.

49:24

So.

49:34

Got this little filling defect here.

49:38

It looks a little dense.

49:40

So we want to go back and look at our non-contrast images.

49:43

And it was not that dense on the non-contrast.

49:46

Again, that's a phlebolith.

49:48

So we think this is something

49:49

that's enhancing, it's really small.

49:54

This was a relatively low-grade papillary urothelial

49:58

carcinoma, so they don't have to be invasive.

50:01

But the thing about this is it's way down at the bladder

50:04

base, and this is going to be a little bit difficult for

50:07

the urologist to see unless they look immediately on

50:10

entry into the bladder or they retroflex their scope.

50:13

So this can be difficult.

50:17

All right, here's one that I'm, I'm showing you the

50:19

ultrasound first, and of course you look at this

50:22

case and it looks like bilateral hydronephrosis.

50:27

There's lots of reasons why patients

50:28

could have bilateral hydronephrosis.

50:30

They might have retroperitoneal fibrosis,

50:32

they might have a bladder outlet obstruction.

50:35

Here we see the bladder was not particularly dilated,

50:38

and I don't see any dilated ureters behind here.

50:42

So somebody is saying peripelvic cysts.

50:44

Excellent.

50:46

So one of the things that can help you on ultrasound

50:48

is you can look or try to look carefully as

50:51

to whether these all connect up and connect up

50:53

to the renal pelvis, but sometimes it's hard.

50:56

Much easier on our CT urogram to see that these

51:00

are just fluid-filled structures around the

51:03

collecting system mimicking hydronephrosis.

51:06

They can be asymmetric, as in this

51:08

case they may be completely one-sided.

51:10

Um, there are different embryologic origins

51:13

from cortical cysts, so that's all that was.

51:19

Peripelvic cysts.

51:23

How about this case?

51:24

It's a little bit of an eye test,

51:25

but hopefully not too much of one.

51:30

While you're looking at that, somebody

51:31

asked, how do you differentiate a small

51:32

urothelial carcinoma from a bladder polyp?

51:35

I can't, so that, that'll have to be resected to

51:38

know for sure whether it's just a little benign

51:40

polyp, which are not all that common, from a UCC.

51:44

Yeah, a little lipoma.

51:45

Exactly.

51:46

So air, you could think about air, but air

51:49

would normally be non-dependent, so it would

51:51

be as anterior in the bladder as it could be.

51:55

So lipomas are not very common in

51:57

the bladder, but they can occur.

51:59

The other place you might see a

52:00

fat attenuation in the bladder.

52:02

Sometimes you'll see a urine fat level, and what

52:05

that really is, is lymphatic or chylous material.

52:09

And you can see that not uncommonly after

52:11

patients have ablations in their kidneys, often

52:15

will, or even partial nephrectomies will.

52:18

Uh, disrupt the lymphatics of the kidney.

52:20

And sometimes there's a little bit of chyle in the

52:23

urine, or chyluria, and that'll show up as a little

52:26

bit of fat, but it'll be as a fat-fluid level.

52:31

So that was a little lipoma.

52:35

All right.

52:36

This is, this is a little bit similar to one

52:39

we saw before, but a little bit more obvious,

52:41

I think, in terms of what we're dealing with.

52:44

So here's a series of axial images, and we're seeing this

52:48

sort of really dilated structure here, coming to here.

52:52

And this is what it looks like on the coronal.

52:55

So it's obstructed.

52:56

Does anybody know what the rule is called?

52:59

When you, uh, when you have this kind of thing, and

53:02

this is what it looked like on the excretory phase.

53:06

It's a duplicated system.

53:07

It's the Weigert–Meyer rule.

53:08

Exactly.

53:09

So the upper pole has things that

53:11

have vowels, like obstruction.

53:14

Ectopic ureter.

53:16

So you can see that this one is going low, and the lower

53:20

moiety has things that have consonants, or L in lower.

53:23

So you have reflux,

53:26

sometimes, not always.

53:28

So in this case, yes, the Weigert–Meyer rule,

53:30

and you can see how low that's inserting.

53:32

And this really not a lot of function in this upper pole.

53:35

There's a little bit; if we waited long

53:37

enough, we could probably opacify this segment.

53:40

But this is the kind of case where you'd have the

53:41

patient walk around for multiple hours and come

53:44

back if you really wanted to see it opacified.

53:48

All right.

53:51

And then you've got to be careful

53:52

again in those un-opacified segments.

53:55

So if you're looking here on the non-contrast, and

53:57

then again on our delayed, we have this area here.

54:01

You just got to be careful when you review these.

54:03

This is clearly would be easier to see

54:05

if we turned the patient prone, but this

54:08

was just a bladder urothelial cancer.

54:12

And how about this one?

54:17

Trying to kind of testing your

54:18

short-term memory a little bit.

54:20

Yeah, this is a simple ureterocele,

54:22

so it's in an orthotopic location.

54:27

All right, so I want to leave a

54:29

couple of minutes for questions.

54:31

So, um, I tried to give you some tricks to

54:34

deal with un-opacified or tortuous segments.

54:36

Again, judicious use of repeating

54:39

imaging, especially turning the patient in

54:42

another direction, either prone or supine.

54:44

If you started one of the other ways, or if you have

54:46

a very tortuous segment, repeating the patient in

54:49

expiration, there's lots of causes of hematuria, and

54:53

not all of them are stones or urothelial cancer.

54:57

So think about things like papillary

54:58

necrosis, that very typical little dot on

55:02

a CT. Um, I didn't show any cases of, of

55:07

infectious.

55:07

I didn't show too many infectious causes, but focal

55:10

cystitis, pyelitis can also be sources of hematuria.

55:13

But hopefully if the patient has a urinary tract infection

55:16

or pyelonephritis, that's really a clinical diagnosis.

55:19

And hopefully you're not getting a CT urogram unless

55:22

they have repeated bouts and you're looking for

55:23

something like a calyceal diverticulum or a bladder

55:26

diverticulum or some other nidus of infection.

55:30

When you look at urothelial cancers, you

55:32

really need to look at those bone windows.

55:35

Um, but if you're looking in an un-opacified segment,

55:38

a liver window or a narrow window might help you see

55:40

something that's a little bit denser than the urine.

55:44

I wanted to show this as a, I'm calling

55:46

my rubber duck artifact.

55:48

It was a friend of mine who gave me this case.

55:50

It looks like a little rubber

55:51

ducky floating in the bladder here.

55:53

So those are the cases that I have.

55:55

Um, I'm just going to say, let me see if I

55:58

can find a few of these questions here.

56:01

Can you please say again your standard

56:02

protocol for hematuria without stone?

56:05

So, in patients who are less than 40, we do our split bolus.

56:10

So we, um, give the patient a little bit of contrast.

56:14

We have them wait around, and then we

56:16

give them another bolus of contrast.

56:18

And so we have an excretory phase

56:19

at the same time as we have our nephrographic phase.

56:22

We start everybody with a non-contrast,

56:25

unless they've had one recently at our place.

56:27

If they've had one recently, we can usually forego

56:29

that because we can just use that one. Over 40,

56:32

we give one bolus, we scan it about

56:34

a hundred seconds for nephrographic.

56:36

So hopefully we're getting nice opacification of the

56:39

cortex and medulla.

56:41

And then we do an excretory phase.

56:43

Our techs are very good at checking the scans and

56:46

looking for segments that didn't opacify well.

56:49

So they will repeat patients.

56:50

And if patients are willing to turn over and do the repeat

56:54

prone, we've been doing all of the repeats prone again.

56:58

So do I prefer MRU?

57:01

Personally, I don't.

57:02

I don't.

57:03

But if the patient cannot have contrast material,

57:07

intravenous iodinated contrast for some reason,

57:10

they have a really severe allergy, or their urinary

57:13

function is borderline, then we will do urography.

57:17

Um, I think it's, I think they're harder to interpret.

57:22

I think they're harder to, in some

57:24

sense, to see everything really well.

57:26

But that might be a little bit of my bias

57:28

because I don't do a lot of MR. I'm more of a CT person

57:31

and an ultrasound person, so I don't prefer it in most cases.

57:37

Um, I talked a little bit about differentiating peristalsis

57:40

from UCC, so I think, um, what else, what have we got here?

57:47

Uh, what CT protocol do we do for

57:49

suspected idiopathic UPJ obstructions?

57:52

Um, again, our usual protocol using a single

57:56

bolus gives us enough opacification of the vessels.

58:00

I think at that hundred seconds,

58:01

that might be all you need.

58:03

If there is a specific request from a surgeon

58:08

for surgical planning for UPJ obstruction, then I think

58:11

adding an arterial phase to make sure that there's

58:15

not a crossing artery is probably not a bad idea.

58:19

But again, I would not do the entire body;

58:21

I would just focus that to the level of the kidneys.

58:27

Cases of multiple septa on kidney cysts on ultrasound.

58:30

Is there a point in doing

58:33

MSCT, because many septa are invisible on it?

58:35

Yeah, I agree with you that multiseptated cysts

58:38

are difficult, and they're usually

58:41

not what we're trying to work up on a CTU.

58:43

But just as an aside, um, contrast-enhanced

58:46

ultrasound for those cases, or MRI with

58:49

subtracted imaging is probably better for those.

58:52

How do I image a pregnant lady with

58:54

unilateral hydro on ultrasound?

58:56

That could be a whole

58:58

whole other thing.

58:59

Um, we have tried, in some cases, MRI can

59:02

be helpful for those to see if you can see

59:04

an abrupt cutoff of where the ureter is.

59:06

And then a judicious use of perhaps a plain

59:09

film, perhaps, to see if there's a stone there.

59:11

Um, ultrasound, you try your best

59:14

to see if you can figure it out.

59:16

Seeing a ureteral jet on the side that's got

59:20

hydro is helpful to make you feel better

59:22

that they're not completely obstructed.

59:24

And it probably also depends on, you know,

59:26

what kinds of symptoms they're having.

59:28

Is it abrupt?

59:29

Is there associated hematuria, and things like that?

59:32

So you've got to kind of put that all in perspective.

59:37

Um, anything else?

59:38

Findings in a neurogenic bladder.

59:40

So neurogenic bladders, thick-walled, etc.,

59:44

so they have sort of a crinkly appearance.

59:47

Um, in severe cases we call them, um, pine tree

59:50

or Christmas tree look, where they're very, if you

59:53

have a coronal, they're kind of skinnier on top

59:55

and fatter on the bottom and go in and out a lot.

59:58

Um, in those cases you might have some back pressure on

60:02

the collecting system, so there might be some fullness.

60:06

Um, they may not empty completely.

60:08

If you look for, um, post-void, that sort of thing.

60:13

Uh, how do I differentiate ureteritis from carcinoma?

60:17

Um, ureteritis is usually a more diffuse

60:21

inflammatory process, so there's more

60:24

uniform hyperenhancement of the mucosa

60:27

and not particularly lobular or focal.

60:30

Um, so that can be helpful.

60:31

Sometimes it's difficult.

60:33

Um, if you see anything that looks a little more focal or

60:37

a little bumpier, you can suggest it might be a carcinoma.

60:41

And then sometimes they do a biopsy or they do,

60:44

uh, urine cytology, and they don't find anything.

60:47

Um, there was a question earlier about how often patients

60:50

have urothelial carcinoma but have a negative cytology.

60:53

I know it happens because they may not be shedding those

60:56

cells every time that you're getting a urine sample.

61:00

I wish I could tell you the percentage that that

61:02

happens, but I don't really know, um, how often

61:06

it happens that you don't have positive cytology

61:10

when you actually indeed have a urothelial cancer.

61:13

It's probably more common to have a negative

61:15

cytology if you have a very small burden of

61:18

urothelial cancer or if it's lower grade.

61:21

So.

61:22

Maybe more, um, papillary kind of thing.

61:26

Can a patient have urothelial carcinoma, you

61:27

know, with a normal urine cytology?

61:29

Yes, they can, but it's not.

61:31

Um, and I don't know again how often that happens.

61:35

Um, I think we're about at our time.

61:37

Um, I enjoyed, uh, speaking to you.

61:41

Um, thank you so much for those of

61:42

you that typed in answers and things.

61:45

I always find it easier, or not easier, easier

61:47

to talk when I have some of your interaction.

61:49

And since you all are remote from me, seeing you

61:52

guys typing things encouraged me to continue.

61:55

So

61:55

thank you very much.

61:58

Well, thank you, Dr. Baumgarten, for such an

61:59

amazing review of these awesome cases and

62:02

everyone else for participating so much.

62:04

This was really, really great.

62:06

Um, I know I learned a lot.

62:08

I'm glad.

62:09

Thank you.

62:10

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62:12

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62:17

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62:19

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62:22

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62:25

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62:28

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62:31

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62:36

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