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Multi–Detector Row CT Urography in the Evaluation of Hematuria¹

¹ From the Department of Radiology, Beth Israel Medical Center, 1st Ave at 16th St, New York, NY 10003. Presented as an education exhibit at the 2002 RSNA scientific assembly. Received March 28, 2003; revision requested April 15; revision received May 21; accepted May 27. Address correspondence to S.A.J. (e-mail: sjoffe@bethisraelny.org).

View larger version (137K): [in a new window]   Figure 1a. Bosniak category II renal cyst in a 47-year-old man. (a) Axial unenhanced CT scan demonstrates a large cyst with an attenuation value of 23 HU at the upper pole of the left kidney. (b) On an axial nephrographic-phase CT scan, the cyst has an attenuation value of 25 HU, indicating no significant enhancement.

View larger version (141K): [in a new window]   Figure 1b. Bosniak category II renal cyst in a 47-year-old man. (a) Axial unenhanced CT scan demonstrates a large cyst with an attenuation value of 23 HU at the upper pole of the left kidney. (b) On an axial nephrographic-phase CT scan, the cyst has an attenuation value of 25 HU, indicating no significant enhancement.

View larger version (148K): [in a new window]   Figure 2a. Renal cell carcinoma in a 52-year-old woman. (a) Axial nephrographic-phase CT scan demonstrates a heterogeneous mass with central necrosis at the upper pole of the right kidney (arrows). (b) Coronal excretory-phase MIP image demonstrates the relationship of the mass (arrows) to the collecting system.

View larger version (114K): [in a new window]   Figure 2b. Renal cell carcinoma in a 52-year-old woman. (a) Axial nephrographic-phase CT scan demonstrates a heterogeneous mass with central necrosis at the upper pole of the right kidney (arrows). (b) Coronal excretory-phase MIP image demonstrates the relationship of the mass (arrows) to the collecting system.

View larger version (132K): [in a new window]   Figure 3a. Papillary necrosis in a 51-year-old man. (a) Excretory-phase CT scan demonstrates small collections of contrast material in the papillae (arrows). (b, c) Coronal MIP (b) and multiplanar reformatted (c) images demonstrate involvement of multiple papillae bilaterally (arrows).

View larger version (87K): [in a new window]   Figure 3b. Papillary necrosis in a 51-year-old man. (a) Excretory-phase CT scan demonstrates small collections of contrast material in the papillae (arrows). (b, c) Coronal MIP (b) and multiplanar reformatted (c) images demonstrate involvement of multiple papillae bilaterally (arrows).

View larger version (81K): [in a new window]   Figure 3c. Papillary necrosis in a 51-year-old man. (a) Excretory-phase CT scan demonstrates small collections of contrast material in the papillae (arrows). (b, c) Coronal MIP (b) and multiplanar reformatted (c) images demonstrate involvement of multiple papillae bilaterally (arrows).

View larger version (124K): [in a new window]   Figure 4a. Caliceal diverticulum with calculi in a 64-year-old man. (a, b) Axial unenhanced (a) and nephrographic-phase (b) CT scans demonstrate calculi (arrowhead) layering in a fluid collection (black arrow in b) at the lower pole of the left kidney. An inferior vena cava filter (white arrow) is incidentally noted. (c, d) Axial excretory-phase CT scans demonstrate contrast material excretion into a portion of the fluid collection (arrow), a finding that represents a caliceal diverticulum. An unenhanced fluid-attenuation mass representing a cyst is seen adjacent to the diverticulum (arrowhead in d). (e) Excretory-phase MIP image demonstrates the caliceal diverticulum (arrow).

View larger version (129K): [in a new window]   Figure 4b. Caliceal diverticulum with calculi in a 64-year-old man. (a, b) Axial unenhanced (a) and nephrographic-phase (b) CT scans demonstrate calculi (arrowhead) layering in a fluid collection (black arrow in b) at the lower pole of the left kidney. An inferior vena cava filter (white arrow) is incidentally noted. (c, d) Axial excretory-phase CT scans demonstrate contrast material excretion into a portion of the fluid collection (arrow), a finding that represents a caliceal diverticulum. An unenhanced fluid-attenuation mass representing a cyst is seen adjacent to the diverticulum (arrowhead in d). (e) Excretory-phase MIP image demonstrates the caliceal diverticulum (arrow).

View larger version (110K): [in a new window]   Figure 4c. Caliceal diverticulum with calculi in a 64-year-old man. (a, b) Axial unenhanced (a) and nephrographic-phase (b) CT scans demonstrate calculi (arrowhead) layering in a fluid collection (black arrow in b) at the lower pole of the left kidney. An inferior vena cava filter (white arrow) is incidentally noted. (c, d) Axial excretory-phase CT scans demonstrate contrast material excretion into a portion of the fluid collection (arrow), a finding that represents a caliceal diverticulum. An unenhanced fluid-attenuation mass representing a cyst is seen adjacent to the diverticulum (arrowhead in d). (e) Excretory-phase MIP image demonstrates the caliceal diverticulum (arrow).

View larger version (111K): [in a new window]   Figure 4d. Caliceal diverticulum with calculi in a 64-year-old man. (a, b) Axial unenhanced (a) and nephrographic-phase (b) CT scans demonstrate calculi (arrowhead) layering in a fluid collection (black arrow in b) at the lower pole of the left kidney. An inferior vena cava filter (white arrow) is incidentally noted. (c, d) Axial excretory-phase CT scans demonstrate contrast material excretion into a portion of the fluid collection (arrow), a finding that represents a caliceal diverticulum. An unenhanced fluid-attenuation mass representing a cyst is seen adjacent to the diverticulum (arrowhead in d). (e) Excretory-phase MIP image demonstrates the caliceal diverticulum (arrow).

View larger version (86K): [in a new window]   Figure 4e. Caliceal diverticulum with calculi in a 64-year-old man. (a, b) Axial unenhanced (a) and nephrographic-phase (b) CT scans demonstrate calculi (arrowhead) layering in a fluid collection (black arrow in b) at the lower pole of the left kidney. An inferior vena cava filter (white arrow) is incidentally noted. (c, d) Axial excretory-phase CT scans demonstrate contrast material excretion into a portion of the fluid collection (arrow), a finding that represents a caliceal diverticulum. An unenhanced fluid-attenuation mass representing a cyst is seen adjacent to the diverticulum (arrowhead in d). (e) Excretory-phase MIP image demonstrates the caliceal diverticulum (arrow).

View larger version (91K): [in a new window]   Figure 5a. Medullary sponge kidney and an obstructing calculus in the right distal ureter in a 62-year-old woman. (a) Axial unenhanced CT scan demonstrates right hydronephrosis (arrowheads) with a nonobstructing calculus (arrow). (b) Axial unenhanced CT scan demonstrates a calculus in the distal right ureter (arrow). (c, d) Axial excretory-phase CT scan (c) and post-CT radiograph (d) demonstrate a paintbrush appearance in the papillae of the left kidney (arrows). Right hydronephrosis is again noted (arrowheads in c).

View larger version (102K): [in a new window]   Figure 5b. Medullary sponge kidney and an obstructing calculus in the right distal ureter in a 62-year-old woman. (a) Axial unenhanced CT scan demonstrates right hydronephrosis (arrowheads) with a nonobstructing calculus (arrow). (b) Axial unenhanced CT scan demonstrates a calculus in the distal right ureter (arrow). (c, d) Axial excretory-phase CT scan (c) and post-CT radiograph (d) demonstrate a paintbrush appearance in the papillae of the left kidney (arrows). Right hydronephrosis is again noted (arrowheads in c).

View larger version (67K): [in a new window]   Figure 5c. Medullary sponge kidney and an obstructing calculus in the right distal ureter in a 62-year-old woman. (a) Axial unenhanced CT scan demonstrates right hydronephrosis (arrowheads) with a nonobstructing calculus (arrow). (b) Axial unenhanced CT scan demonstrates a calculus in the distal right ureter (arrow). (c, d) Axial excretory-phase CT scan (c) and post-CT radiograph (d) demonstrate a paintbrush appearance in the papillae of the left kidney (arrows). Right hydronephrosis is again noted (arrowheads in c).

View larger version (105K): [in a new window]   Figure 5d. Medullary sponge kidney and an obstructing calculus in the right distal ureter in a 62-year-old woman. (a) Axial unenhanced CT scan demonstrates right hydronephrosis (arrowheads) with a nonobstructing calculus (arrow). (b) Axial unenhanced CT scan demonstrates a calculus in the distal right ureter (arrow). (c, d) Axial excretory-phase CT scan (c) and post-CT radiograph (d) demonstrate a paintbrush appearance in the papillae of the left kidney (arrows). Right hydronephrosis is again noted (arrowheads in c).

View larger version (141K): [in a new window]   Figure 6a. Nephrocalcinosis in a 33-year-old woman. Axial unenhanced (a) and excretory-phase (b) CT scans demonstrate medullary calcifications bilaterally (arrowheads). Left hydronephrosis is also noted (arrow in b). The calcifications were not visible at abdominal radiography.

View larger version (116K): [in a new window]   Figure 6b. Nephrocalcinosis in a 33-year-old woman. Axial unenhanced (a) and excretory-phase (b) CT scans demonstrate medullary calcifications bilaterally (arrowheads). Left hydronephrosis is also noted (arrow in b). The calcifications were not visible at abdominal radiography.

View larger version (133K): [in a new window]   Figure 7a. Transitional cell carcinoma of the left ureter with associated left hydronephrosis in a 77-year-old woman. (a) Axial nephrographic-phase CT scan demonstrates left hydronephrosis (arrowheads) with associated delayed medullary enhancement (arrows). (b) Axial nephrographic-phase CT scan demonstrates left hydroureter (arrowheads). (c) Axial nephrographic-phase CT scan obtained several centimeters below b demonstrates an enhancing mass in the ureter (arrow). (d) Coronal excretory-phase reformatted image demonstrates left hydronephrosis and hydroureter (arrowheads) with an obstructing soft-tissue mass in the ureter (arrow).

View larger version (117K): [in a new window]   Figure 7b. Transitional cell carcinoma of the left ureter with associated left hydronephrosis in a 77-year-old woman. (a) Axial nephrographic-phase CT scan demonstrates left hydronephrosis (arrowheads) with associated delayed medullary enhancement (arrows). (b) Axial nephrographic-phase CT scan demonstrates left hydroureter (arrowheads). (c) Axial nephrographic-phase CT scan obtained several centimeters below b demonstrates an enhancing mass in the ureter (arrow). (d) Coronal excretory-phase reformatted image demonstrates left hydronephrosis and hydroureter (arrowheads) with an obstructing soft-tissue mass in the ureter (arrow).

View larger version (123K): [in a new window]   Figure 7c. Transitional cell carcinoma of the left ureter with associated left hydronephrosis in a 77-year-old woman. (a) Axial nephrographic-phase CT scan demonstrates left hydronephrosis (arrowheads) with associated delayed medullary enhancement (arrows). (b) Axial nephrographic-phase CT scan demonstrates left hydroureter (arrowheads). (c) Axial nephrographic-phase CT scan obtained several centimeters below b demonstrates an enhancing mass in the ureter (arrow). (d) Coronal excretory-phase reformatted image demonstrates left hydronephrosis and hydroureter (arrowheads) with an obstructing soft-tissue mass in the ureter (arrow).

View larger version (151K): [in a new window]   Figure 7d. Transitional cell carcinoma of the left ureter with associated left hydronephrosis in a 77-year-old woman. (a) Axial nephrographic-phase CT scan demonstrates left hydronephrosis (arrowheads) with associated delayed medullary enhancement (arrows). (b) Axial nephrographic-phase CT scan demonstrates left hydroureter (arrowheads). (c) Axial nephrographic-phase CT scan obtained several centimeters below b demonstrates an enhancing mass in the ureter (arrow). (d) Coronal excretory-phase reformatted image demonstrates left hydronephrosis and hydroureter (arrowheads) with an obstructing soft-tissue mass in the ureter (arrow).

View larger version (109K): [in a new window]   Figure 8a. UPJ obstruction and nonobstructing calculi in a 35-year-old man. (a, b) Axial unenhanced (a) and excretory-phase (b) CT scans demonstrate right hydronephrosis with thickening of the urothelium in the renal pelvis (arrowheads). Note the calculi layering in the collecting system (arrows in a). (c) Three-dimensional VR image of the collecting systems demonstrates right hydronephrosis due to UPJ obstruction. Note that the left renal collecting system is incompletely distended.

View larger version (123K): [in a new window]   Figure 8b. UPJ obstruction and nonobstructing calculi in a 35-year-old man. (a, b) Axial unenhanced (a) and excretory-phase (b) CT scans demonstrate right hydronephrosis with thickening of the urothelium in the renal pelvis (arrowheads). Note the calculi layering in the collecting system (arrows in a). (c) Three-dimensional VR image of the collecting systems demonstrates right hydronephrosis due to UPJ obstruction. Note that the left renal collecting system is incompletely distended.

View larger version (129K): [in a new window]   Figure 8c. UPJ obstruction and nonobstructing calculi in a 35-year-old man. (a, b) Axial unenhanced (a) and excretory-phase (b) CT scans demonstrate right hydronephrosis with thickening of the urothelium in the renal pelvis (arrowheads). Note the calculi layering in the collecting system (arrows in a). (c) Three-dimensional VR image of the collecting systems demonstrates right hydronephrosis due to UPJ obstruction. Note that the left renal collecting system is incompletely distended.

View larger version (123K): [in a new window]   Figure 9a. Transitional cell carcinoma of the renal pelvis and ureteral perforation that occurred during ureteroscopy in a 47-year-old man. (a-c) Axial unenhanced (a), nephrographic-phase (b), and excretory-phase (c) CT scans demonstrate an enhancing soft-tissue mass in the renal pelvis (arrows) with no invasion of the renal parenchyma. (d, e) Axial CT scan (d) and coronal MIP image (e) demonstrate a large collection of contrast material (arrowheads) adjacent to the ureter (arrow in d) due to perforation of the proximal ureter. The irregular filling defect in e (arrows) represents transitional cell carcinoma.

View larger version (130K): [in a new window]   Figure 9b. Transitional cell carcinoma of the renal pelvis and ureteral perforation that occurred during ureteroscopy in a 47-year-old man. (a-c) Axial unenhanced (a), nephrographic-phase (b), and excretory-phase (c) CT scans demonstrate an enhancing soft-tissue mass in the renal pelvis (arrows) with no invasion of the renal parenchyma. (d, e) Axial CT scan (d) and coronal MIP image (e) demonstrate a large collection of contrast material (arrowheads) adjacent to the ureter (arrow in d) due to perforation of the proximal ureter. The irregular filling defect in e (arrows) represents transitional cell carcinoma.

View larger version (120K): [in a new window]   Figure 9c. Transitional cell carcinoma of the renal pelvis and ureteral perforation that occurred during ureteroscopy in a 47-year-old man. (a-c) Axial unenhanced (a), nephrographic-phase (b), and excretory-phase (c) CT scans demonstrate an enhancing soft-tissue mass in the renal pelvis (arrows) with no invasion of the renal parenchyma. (d, e) Axial CT scan (d) and coronal MIP image (e) demonstrate a large collection of contrast material (arrowheads) adjacent to the ureter (arrow in d) due to perforation of the proximal ureter. The irregular filling defect in e (arrows) represents transitional cell carcinoma.

View larger version (127K): [in a new window]   Figure 9d. Transitional cell carcinoma of the renal pelvis and ureteral perforation that occurred during ureteroscopy in a 47-year-old man. (a-c) Axial unenhanced (a), nephrographic-phase (b), and excretory-phase (c) CT scans demonstrate an enhancing soft-tissue mass in the renal pelvis (arrows) with no invasion of the renal parenchyma. (d, e) Axial CT scan (d) and coronal MIP image (e) demonstrate a large collection of contrast material (arrowheads) adjacent to the ureter (arrow in d) due to perforation of the proximal ureter. The irregular filling defect in e (arrows) represents transitional cell carcinoma.

View larger version (126K): [in a new window]   Figure 9e. Transitional cell carcinoma of the renal pelvis and ureteral perforation that occurred during ureteroscopy in a 47-year-old man. (a-c) Axial unenhanced (a), nephrographic-phase (b), and excretory-phase (c) CT scans demonstrate an enhancing soft-tissue mass in the renal pelvis (arrows) with no invasion of the renal parenchyma. (d, e) Axial CT scan (d) and coronal MIP image (e) demonstrate a large collection of contrast material (arrowheads) adjacent to the ureter (arrow in d) due to perforation of the proximal ureter. The irregular filling defect in e (arrows) represents transitional cell carcinoma.

View larger version (110K): [in a new window]   Figure 10a. Vascular impression on the left renal pelvis in a 25-year-old woman. (a) Intravenous urogram demonstrates a nonspecific filling defect in the left renal pelvis (arrows). (b) Three-dimensional VR image (posterior projection) demonstrates the filling defect (arrows). (c, d) Sagittal reformatted image (c) and axial excretory-phase CT scan (d) demonstrate an extrinsic impression on the posterior aspect of the renal pelvis (arrows). (e) Axial nephrographic-phase CT scan demonstrates a branch of the left renal vein (arrowheads) that is causing the extrinsic impression on the renal pelvis.

View larger version (132K): [in a new window]   Figure 10b. Vascular impression on the left renal pelvis in a 25-year-old woman. (a) Intravenous urogram demonstrates a nonspecific filling defect in the left renal pelvis (arrows). (b) Three-dimensional VR image (posterior projection) demonstrates the filling defect (arrows). (c, d) Sagittal reformatted image (c) and axial excretory-phase CT scan (d) demonstrate an extrinsic impression on the posterior aspect of the renal pelvis (arrows). (e) Axial nephrographic-phase CT scan demonstrates a branch of the left renal vein (arrowheads) that is causing the extrinsic impression on the renal pelvis.

View larger version (102K): [in a new window]   Figure 10c. Vascular impression on the left renal pelvis in a 25-year-old woman. (a) Intravenous urogram demonstrates a nonspecific filling defect in the left renal pelvis (arrows). (b) Three-dimensional VR image (posterior projection) demonstrates the filling defect (arrows). (c, d) Sagittal reformatted image (c) and axial excretory-phase CT scan (d) demonstrate an extrinsic impression on the posterior aspect of the renal pelvis (arrows). (e) Axial nephrographic-phase CT scan demonstrates a branch of the left renal vein (arrowheads) that is causing the extrinsic impression on the renal pelvis.

View larger version (79K): [in a new window]   Figure 10d. Vascular impression on the left renal pelvis in a 25-year-old woman. (a) Intravenous urogram demonstrates a nonspecific filling defect in the left renal pelvis (arrows). (b) Three-dimensional VR image (posterior projection) demonstrates the filling defect (arrows). (c, d) Sagittal reformatted image (c) and axial excretory-phase CT scan (d) demonstrate an extrinsic impression on the posterior aspect of the renal pelvis (arrows). (e) Axial nephrographic-phase CT scan demonstrates a branch of the left renal vein (arrowheads) that is causing the extrinsic impression on the renal pelvis.

View larger version (109K): [in a new window]   Figure 10e. Vascular impression on the left renal pelvis in a 25-year-old woman. (a) Intravenous urogram demonstrates a nonspecific filling defect in the left renal pelvis (arrows). (b) Three-dimensional VR image (posterior projection) demonstrates the filling defect (arrows). (c, d) Sagittal reformatted image (c) and axial excretory-phase CT scan (d) demonstrate an extrinsic impression on the posterior aspect of the renal pelvis (arrows). (e) Axial nephrographic-phase CT scan demonstrates a branch of the left renal vein (arrowheads) that is causing the extrinsic impression on the renal pelvis.

View larger version (124K): [in a new window]   Figure 11. Transitional cell carcinoma of the bladder in a 79-year-old man. Excretory-phase CT scan demonstrates a papillary mass in the right side of the bladder (arrow). Note the impression on the bladder base caused by the enlarged prostate gland (arrowheads).

View larger version (113K): [in a new window]   Figure 12. Neurogenic bladder and multiple diverticula in a 25-year-old man. CT scan shows diverticula (arrows).

View larger version (126K): [in a new window]   Figure 13a. Horseshoe kidney and long-standing hydronephrosis of the left kidney in a 33-year-old man. (a, b) Axial nephrographic-phase (a) and excretory-phase (b) CT scans demonstrate hydronephrosis of the left kidney (arrows) with atrophy of the kidney. Note the contrast material layering in the renal collecting system on the excretory-phase image (arrowhead in b) due to the lack of mixing with the urine in the dilated renal pelvis. (c) Excretory-phase VR image demonstrates a horseshoe kidney. Note that the left renal collecting system is not well opacified (arrows) due to the layering of contrast material in the hydronephrotic kidney.

View larger version (127K): [in a new window]   Figure 13b. Horseshoe kidney and long-standing hydronephrosis of the left kidney in a 33-year-old man. (a, b) Axial nephrographic-phase (a) and excretory-phase (b) CT scans demonstrate hydronephrosis of the left kidney (arrows) with atrophy of the kidney. Note the contrast material layering in the renal collecting system on the excretory-phase image (arrowhead in b) due to the lack of mixing with the urine in the dilated renal pelvis. (c) Excretory-phase VR image demonstrates a horseshoe kidney. Note that the left renal collecting system is not well opacified (arrows) due to the layering of contrast material in the hydronephrotic kidney.

View larger version (90K): [in a new window]   Figure 13c. Horseshoe kidney and long-standing hydronephrosis of the left kidney in a 33-year-old man. (a, b) Axial nephrographic-phase (a) and excretory-phase (b) CT scans demonstrate hydronephrosis of the left kidney (arrows) with atrophy of the kidney. Note the contrast material layering in the renal collecting system on the excretory-phase image (arrowhead in b) due to the lack of mixing with the urine in the dilated renal pelvis. (c) Excretory-phase VR image demonstrates a horseshoe kidney. Note that the left renal collecting system is not well opacified (arrows) due to the layering of contrast material in the hydronephrotic kidney.

View larger version (178K): [in a new window]   Figure 14a. Duplication of the left renal collecting system and ureter in a 48-year-old man. (a) Axial excretory-phase CT scan demonstrates two left ureters (arrowheads). (b) Excretory-phase VR image demonstrates duplication of the left renal collecting system (arrows) and ureters (arrowheads).

View larger version (166K): [in a new window]   Figure 14b. Duplication of the left renal collecting system and ureter in a 48-year-old man. (a) Axial excretory-phase CT scan demonstrates two left ureters (arrowheads). (b) Excretory-phase VR image demonstrates duplication of the left renal collecting system (arrows) and ureters (arrowheads).

View larger version (85K): [in a new window]   Figure 15a. Ureterocele in a 31-year-old woman. The left kidney had been removed many years earlier due to an unknown "benign cause." (a) Axial excretory-phase CT scan demonstrates right hydronephrosis (arrows). (b) Axial excretory-phase CT scan demonstrates a dilated ureter (arrowhead) terminating in a ureterocele (arrows). (c) Excretory-phase VR image demonstrates hydronephrosis (black arrows), hydroureter (arrowhead), and the ureterocele (white arrow).

View larger version (81K): [in a new window]   Figure 15b. Ureterocele in a 31-year-old woman. The left kidney had been removed many years earlier due to an unknown "benign cause." (a) Axial excretory-phase CT scan demonstrates right hydronephrosis (arrows). (b) Axial excretory-phase CT scan demonstrates a dilated ureter (arrowhead) terminating in a ureterocele (arrows). (c) Excretory-phase VR image demonstrates hydronephrosis (black arrows), hydroureter (arrowhead), and the ureterocele (white arrow).

View larger version (135K): [in a new window]   Figure 15c. Ureterocele in a 31-year-old woman. The left kidney had been removed many years earlier due to an unknown "benign cause." (a) Axial excretory-phase CT scan demonstrates right hydronephrosis (arrows). (b) Axial excretory-phase CT scan demonstrates a dilated ureter (arrowhead) terminating in a ureterocele (arrows). (c) Excretory-phase VR image demonstrates hydronephrosis (black arrows), hydroureter (arrowhead), and the ureterocele (white arrow).