“ROLE OF MULTIDETECTOR CT UROGRAPHY IN EVALUATION

OF CAUSES OF HAEMATURIA.”

By

DR. MAITHRI S PATEL MBBS

Dissertation submitted to the Rajiv Gandhi University of Health Sciences,

Bangalore, Karnataka.

In partial fulfilment of the requirements for the degree of

DOCTOR OF MEDICINE

IN

RADIO-DIAGNOSIS

Under the Guidance of

DR. H.V RAMPRAKASH MBBS, MD (PROFESSOR)

DEPARTMENT OF RADIODIAGNOSIS & IMAGING VYDEHI INSTITUTE OF

MEDICAL SCIENCES & RESEARCH CENTRE, WHITEFIELD, BANGALORE.

2016-2019

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LIST OF ABBREVIATIONS USED

AUA American urological association

BPH Benign Prostatic hyperplasia

CKD Chronic kidney disease

CT Computed tomography

CTU Computed tomography urography

DICO M Digital imaging and communication in medicine

IVP Intravenous pyelogram

IVU Intravenous urogram

MDC T Multi-detector computed tomography

MDCTU Multi-detector computed tomography

MIP Maximum intensity projections

MPR Multiplanar reconstruction

MRI Magnetic resonance imaging

MRU Magnetic resonance urogram

MSCT Multi-slice computed tomography

NSAID’s Non-steroidal anti-inflammatory drugs

PACS Picture archiving and communication systems

RBCs Red blood cells

RCC Renal cell carcinoma

TCC Transitional cell carcinoma

UTI Urinary tract infections

UUT-UCC Upper urinary tract urothelial cell carcinoma

VR Volume rendering

VUJ Vesico-ureteric junction

viii

LIST OF TABLES

x

Sl no. Particulars Page no.

1. Causes of hematuria in various sites. 6

2. Causes of hematuria by symptoms and location 7

3. MDCT Urography findings among patients with hematuria 32

4. Distribution of the subjects according to age group. 40

5. Distribution of the subjects according to sex 41

6. Distribution of subjects according to type of hematuria 42

7. Distribution of the subjects according to associated symptoms 43

8. Distribution of the subjects according to causes of hematuria 44

9. Distribution of subjects according to causes of hematuria and type of 45 hematuria

10. Distribution of subjects according to causes of hematuria and associated 47 symptoms

11. Distribution of the subjects according to type of haematuria and 49 percentage showing associated symptoms

12. Distribution according to calculi location 50

13. Distribution of Features of Renal Carcinoma 51

14. Distribution of Features of bladder Carcinoma 52

15. Distribution of subjects according age group and cause of haematuria 53

16. Distribution of subjects according sex and cause of haematuria 55

LIST OF FIGURES Sl no. Particulars Page no.

1. Anatomy of urinary system 8

2. Anatomy of kidney 9

3. Bosniak classification of renal cysts 29

4. Image of MDCT scanner at VIMS & RC 38

5.(a&b) Axial image of CECT scan of upper abdomen showing 57

heterogeneously enhancing mass in the left kidney showing left renal

vein(a) and left adrenals(b)

6. MDCT MPR coronal image of the abdomen and pelvis showing left 57

sided varicocele in a case of left sided renal cell carcinoma causing left

renal vein invasion

7.(a&b) Axial nephrogenic(7a) and urographic(7b) images of the pelvis 58

showing enhancing papillary growth in the posterior and left lateral

wall of urinary bladder involving the left ureter and vesico-ureteric

junction.

8.(a&b) Axial and coronal images of abdomen showing well defined enhancing 59

soft tissue lesion within the lumen of the right ureter .

9. MDCT MPR Coronal image of the abdomen in corticomedullary phase 59

showing a wedge shaped hypoattenuating hypoenhancing area in the

mid and lower pole of the right kidney.

10. MDCT MRP Sagittal image in corticomedullary phase showing a 60

extracapsular hematoma along the mid and lower pole of the right

kidney seen communicating with the intraparenchymal hematoma.

11. Axial image at the level of the kidneys of the same subject as in figure 60

10 and 11 shows no extension of the intraparenchymal hematoma into

the renal pelvis and normal renal hilar vessels.

12. Axial image in urographic phase of the same subject in Figure 10 & 11 61

shows normal excretion of contrast into the renal pelvis with minimal

narrowing of the proximal ureter.

13. MDCT MPR coronal image of the abdomen in unenhanced phase 61

shows staghorn calculus in the left kidney.

xii

ABSTRACT

BACKGROUND

Haematuria is presence of blood in urine it can be gross (visible)or microscopic

haematuria. Microscopic haematuria is presence of 3 or more RBC’s per high powered field

in 2 or 3 urine specimens. Hematuria is one of the most common manifestations of urinary

tract pathologies such as calculi, neoplasm, infection, trauma, medications, coagulopathy,

developmental anomalies, and renal parenchymal diseases involving the renal system.

The main purpose of imaging investigations for haematuria is to identify the cause at the

earliest to improve prognosis. Conventional radiography and intravenous urography (IVU)

were the standard imaging techniques. Ultrasonography (USG) is the modality of choice in

clinical practice presently. But the role of CT urography (CTU) is gaining scope as it has the

advantage of identifying and localizing the cause of hematuria where USG fails to do so. It

also has helps evaluate the periureteric tissues and retroperitoneum while excretory urography

only images the lumen.

The concept of CTU is more appropriate as both the renal parenchyma and

urothelium can be evaluated with one relatively non-invasive comprehensive examination.

CT urography represents a single one-stop diagnostic technique for patients with haematuria.

OBJECTIVES

1. To evaluate the role of CT urography in investigating causes of haematuria

2. To determine the sensitivity and specificity of CT urography in evaluation and

differentiation of the upper and lower urinary tract pathologies causing hematuria.

3. To study the most common etiology of haematuria in our region.

xiii

MATERIALS AND METHODS.

A prospective study was conducted on 45 patients who presented with haematuria to the OPD

and were suspected to have a urological cause were referred to the Department of Radio

diagnosis in our hospital in a period of 1.5 years ranging from January 2016 to June 2017.The

patients were subjected to Multi-detector computed tomography (MDCT) Urography and results

were tabulated based on the causes and their location.

The Statistical analysis was performed using SPSS 22 version software. Categorical data was

represented in the form of Frequencies and proportions.

RESULTS:

In our study out of the 45 patients referred for CT Urography, all were found to have positive

findings on Multi-detector CT(MDCT). Most common cause of haematuria was carcinoma of

bladder(37.8%) ,second most common cause being calculus(24.4%),followed by renal cell

carcinoma(17.8%),trauma(8.9%),infection( 6.7%) and ureteric carcinoma(4.4%).

CONCLUSION:

Multidetector CT urography with its multiplanar capabilities detects with high accuracy the

entire spectrum of urinary tract pathologies causing haematuria. Thus, it is the one step modality

of choice in evaluation of causes of hematuria aiding the treating physician/surgeon.

xiv

INTRODUCTION

Hematuria is one of the most common manifestations of urinary tract pathologies such as

calculi, neoplasm, infection, trauma, medications, coagulopathy, developmental anomalies,

and renal parenchymal diseases and always warrants serious concern,1 both to the patient as

well as the treating physician.2 Its reported prevalence does range from 0.2% to 21%.

3

Hematuria, being one of the most common presentations of patients with urinary tract

diseases, is a common reason for urinary tract imaging.4 Hematuria can originate from any

site along the urinary tract and, whether gross or microscopic, may be a sign of serious

underlying disease including malignancy.2

Multidetector Computed Tomography (MDCT)

The advanced MDCT scanners with its superior spatial resolution, higher speed, and isotropic

reconstruction capability has ushered in a revolution in diagnostic imaging of urinary tract

disorders.2 MDCT Urography (MDCTU) gives a detailed anatomic description of the entire

urinary tract in a single breath-hold, thus allowing hematuria patients to be evaluated

comprehensively.2 The superior spatial resolution allows excellent 3D multiplanar reformats.

Recently, it has almost replaced the conventional urography in evaluating the urinary tract.2

MDCTU can acquire thinly collimated data sets, which can be used to create excellent 3D

quality images of the urinary tract.3 MDCTU has the potential to stand alone as a

comprehensive “one-stop” test for imaging the upper and lower urinary tract.5 It is

particularly suitable for patients presenting with hematuria where the urinary tract must be

assessed for both stone disease and neoplasms of the kidney and/or urothelium.5 For patients

with hematuria, MDCTU is also considered as the “gold standard” imaging test for the

evaluation of renal parenchyma for renal masses.5

1

The American Urological Association (AUA) guidelines recommended upper tract imaging

for low-and high-risk patients with microscopic hematuria, defined as three or more Red

Blood Cells (RBCs) per high-power field from two of three properly collected urinalysis

specimens.4 MDCTU, a cross-sectional technique, is less susceptible to overlying bowel gas

and more sensitive for detection of small tumors and calculi.4

The etiologies for gross and microscopic hematuria are vast and include multiple systems in

numerous anatomic locations along the urinary tract. Organization of these etiologies using a

combination of systems and anatomic approach can help the provider make the appropriate

diagnosis and treatment.6

Purpose of imaging investigations for hematuria

Imaging studies may be warranted when certain disease processes are suspected such as

urolithiasis and malignancy. These studies include the Intravenous Pyelogram (IVP), CT,

ultrasonography, and Magnetic Resonance Imaging (MRI).7

Hematuria is determined by nonimaging diagnosis of hematuria and radiology imaging of

hematuria. In both the methods, radiologic imaging plays a vital role in the diagnosis of

hematuria. However, the performances of individual imaging techniques within a specific

diagnostic algorithm for hematuria have not been studied well. Sensitivity and specificity

need to be deducted from diseases that are the major causes of hematuria: urolithiasis,

infection, Renal Cell Carcinoma (RCC), and urothelial cell cancer. There are different types

of radiology imaging techniques, and each plays a different role in the investigation of

hematuria.8 From those techniques, MDCTU by using its multiplanar and 3D capabilities is

highly accurate and specific in detecting the causes of hematuria. It can show the exact site of

involvement in very high percent of cases. In addition to hematuria, MDCT can find out

various associated and incidental findings which may not be suspected clinically.3

2

Sensitivity and specificity of CT Urography (CTU)

Imaging techniques have gained an increasingly crucial role in the diagnosis of bladder cancer;

in particular, Intravenous Urography (IVU) has been the reference standard for decades.

Currently, ultrasound is the first choice of investigation in clinical practice, but requests for CT

have also increased in recent days.9

CTU is an optimized examination for evaluating kidney and urinary tracts and includes high-

resolution excretory phase–enhanced CT. There are 2 major approaches in terms of contrast

material delivery and CT acquisitions: a single-bolus contrast medium injection technique with 3

CT acquisitions during the unenhanced, nephrographic, and excretory phases (i.e., single-bolus

CTU) and a split-bolus contrast medium injection technique with 2 CT acquisitions during the

unenhanced and synchronous nephrographic and excretory phases (i.e., split-bolus CTU). A

higher radiation exposure is one of the major issues of CTU especially in the single-bolus CTU

protocol, but several new imaging techniques have emerged to reduce the radiation dose of

CTU.10

MDCT, with high spatial resolution and advanced post processing techniques, provides IVU-like

images of the urinary tract as well as renal and extra-renal information. This type of examination

is called as CT urography, and it was defined by the European Society of Urogenital Radiology

as a multiphasic imaging technique used to examine the urinary tract, after IV administration of

contrast medium, using MDCT with thin-slice imaging of the renal parenchyma and urinary

tract, including the bladder.9

The purpose of present study is to evaluate the role of MDCT Urography in patients with

haematuria by establishing the cause and location of pathology in the urinary tract.

3

AIMS & OBJECTIVES

1. To evaluate the role of CT urography in investigating causes of haematuria

2. To determine the sensitivity and specificity of CT urography in evaluation and

differentiation of the upper and lower urinary tract pathologies causing hematuria.

3. To study the most common etiology of haematuria in our region.

4

REVIEW OF LITERATURE

Hematuria

Hematuria is most accurately defined as the presence of three or more RBCs per high-power

field in two of three properly collected urinalysis specimens.11

It may be symptomatic or

asymptomatic and occurs in isolation or in association with other urinary tract abnormalities.

11

Hematuria may be painful (classically associated with urinary calculi or UTI) or painless

(classically associated with the underlying malignancies).

Hematuria arising from injury in the glomerular filtration barrier, results in passage of RBCs

into the urinary space; promoting oxidative stress, inflammation, and structural damage to the

kidney.12

Hematuria can also result from infections, urinary stone disease, tumors, or from

other lesions that may obstruct the urinary tract, raising intrarenal pressures, causing

impairment of kidney function.12

Underlying conditions like diabetes producing hematuria

can be associated with a progressive decline in kidney function in the setting of Chronic

Kidney Disease (CKD). Also, hematuria, per se may play a mechanistic role in renal disease

progression. 12

Classification of hematuria

Hematuria is the presence of an abnormal quantity of RBCs in the urine,6 which can be

microscopic or macroscopic (visible to the naked eye) in nature, but both forms may be the

sole manifestation of underlying serious pathology.11

Macroscopic hematuria: It is defined as blood in the urine visible by the naked eye. Patients

often present to the emergency department or at the physician’s office after such an episode.

It conveys a much higher risk of malignancy and warrants prompt investigation in all cases.11

Urinary tract malignancy is 4 times more common in patients with macroscopic hematuria

5

than microscopic hematuria with gross hematuria being the presenting symptom in 80% of bladder

cancers and half of all renal cancers.11

Therefore, patients with macroscopic hematuria require

complete evaluation of the upper and lower urinary tracts with upper urinary tract imaging and

cystoscopy to exclude neoplasia.11

Microscopic hematuria: Microscopic hematuria is defined as ≥3 RBCs per high-power field (X400

magnification) in a single properly collected urine sample.6 It is a common urological problem with a

wide range of causes, including infection, stone disease, tumors of the kidney and the urinary tract,

drug toxicity and coagulopathy.13

Causes of hematuria6

Table 1. Causes of hematuria in various sites

Organ Site Tumor/Malignancy Inflammation Stones Anatomic Abnormality Renal cell carcinoma, Nephropathy, Renal stones Polycystic kidney renal pelvis urothelial pyelonephritis disease, medullary

cell carcinoma, renal , renal sponge kidney, Kidney lymphoma, abscess, renal hydronephrosis, angiomyolipoma, tuberculosis arteriovenous

oncocytoma malformation Ureteral urothelial cell Ureteral Ureteral stricture, carcinoma stones fibroepithelial poyp

Ureter

Bladder urothelial Bacterial Bladder Vesicoureteral reflux,

carcinoma, bladder cystitis, stones cystocele, bladder

squamous cell carcinoma tuberculous papilloma, Bladder cystitis, trabeculated bladder radiation

cystitis, Schistosoma

haematobium Prostate Prostate cancer Prostatitis Prostate stone Benign prostatic hyperplasia

Urethral cancer, penile Urethritis Urethral stricture, Urethra/Pe- cancer urethral diverticulum nis

6

Risks of hematuria

The factors that increase the risk of developing hematuria include:

Inflammatory conditions of the kidney, ureter, or bladder

Prostatitis, an infectious or inflammatory condition of the prostate in men

An enlarged prostate, which typically occurs with hematuria, whether gross or

microscopic, can be caused by benign or more serious conditions. 14

Longer follow-up and use of oral anticoagulants may increase the risk of delayed

hematuria

Delayed hematuria is common after photoselective vaporization 15

Causes of hematuria

Generally reported causes of hematuria may include Urinary Tract Infections (UTIs,) urinary

tract stones, tumors of the bladder and kidney, urethritis, Benign Prostatic Hyperplasia (BPH)

and cancer of the prostate.6 The most common primary malignancies associated with

hematuria are renal cell carcinoma, urothelial cell carcinoma, prostate carcinoma and less

commonly, squamous cell carcinoma.11

The common causes of hematuria classified by

symptoms and location are listed in Table 2.

Table 2. Causes of hematuria by symptoms and location6

Infection Cystitis, tuberculosis, prostatitis, urethritis, schistosomiasis

Renal carcinoma, Wilms tumor, carcinoma of the bladder, prostate cancer,

Malignancy urethral cancer, or endometrial cancer

Renal tract trauma due to accidents, catheter, or foreign body; prolonged

Trauma severe exercise; rapid emptying of an over distended bladder (eg, after

catheterization for acute retention).

Inflammation Post irradiation

Structural Calculi (renal , bladder, ureter ic), simple cysts, polycystic renal disease,

7

BPH, congenital vascular anomalies

Hematological Sickle cell disease, coagulation disorders, anticoagulation therapy

Surgery Invasive procedures to the prostate or bladder

Drugs Analgesics, anticoagulants, sulfonamides, cyclophosphamide, Nonsteroidal

Anti-inflammatory Drugs (NSAIDs), oral contraceptives, penicillin

(extended spectrum), quinine, vincristine

Others Genital bleeding, menstruation, excessive exercise, Munchausen syndrome,

or fabricated or induced illness by caregivers

Anatomy of the urinary system

The organs in the urinary system comprise of:

1. Two kidneys

2. Two ureters

3. Urinary bladder

4. Urethra

Figure 1. Anatomy of urinary system

8

Kidneys: The kidneys are situated in the posterior part of the abdomen, one on either side of

the vertebral column, behind the peritoneum, and surrounded by a mass of fat and loose

areolar tissue. Their upper extremities are on a level with the upper border of the twelfth

thoracic vertebra, their lower extremities on a level with the third lumbar. The right kidney is

usually slightly lower than the left, probably on account of the vicinity of the liver. The long

axis of each kidney is directed downward and lateral; the transverse axis backward and

lateral.

Anterior surface of right kidney - A narrow portion at the upper extremity is in relation with

the right suprarenal gland.16

Figure 2. Anatomy of kidney

Anterior surface of left kidney - A small area along the upper part of the medial border is in

relation with the left suprarenal gland, and close to the lateral border is a long strip in contact

with the renal impression on the spleen.16

9

The posterior surface - The posterior surface of each kidney is directed backward and medial.

It is imbedded in areolar and fatty tissue and entirely devoid of peritoneal covering. It lies

upon the diaphragm, the medial and lateral lumbocostal arches, the psoas major, the

quadratus lumborum, and the tendon of the transversus abdominis, the subcostal, and one or

two of the upper lumbar arteries, and the last thoracic, iliohypogastric, and ilioinguinal

nerves. The right kidney rests upon the twelfth rib, the left usually on the eleventh and

twelfth. The diaphragm separates the kidney from the pleura, which dips down to form the

phrenicocostal sinus, but frequently the muscular fibres of the diaphragm are defective or

absent over a triangular area immediately above the lateral lumbocostal arch, and when this is

the case the perinephric areolar tissue is in contact with the diaphragmatic pleura.16

Borders - The lateral border (margo lateralis; external border) is convex, and is directed

toward the posterolateral wall of the abdomen. On the left side, it is in contact at its upper

part, with the spleen. The medial border (margo medialis; internal border) is concave in the

centre and convex toward either extremity; it is directed forward and a little downward. Its

central part presents a deep longitudinal fissure, bounded by prominent overhanging anterior

and posterior lips. This fissure is named the hilum, and transmits the vessels, nerves, and

ureter. Above the hilum, the medial border is in relation with the suprarenal gland; below the

hilum, with the ureter.

Extremities - The superior extremity (extremitas superior) is thick and rounded, and is nearer

the median line than the lower; it is surmounted by the suprarenal gland, which covers also a

small portion of the anterior surface. The inferior extremity (extremitas inferior) is smaller

and thinner than the superior and farther from the median line. It extends to within 5 cm. of

the iliac crest. The relative position of the main structures in the hilum is as follows: the vein

is in front, the artery in the middle, and the ureter behind and directed downward. Frequently,

however, branches of both artery and vein are placed behind the ureter. 16

10

Microscopic anatomy - The renal tubules, of which the kidney is for the most part made up,

commence in the cortical substance, and after pursuing a very circuitous course through the

cortical and medullary substances, finally end at the apices of the renal pyramids by open

mouths, so that the fluid which they contain is emptied, through the calyces, into the pelvis of

the kidney. The tubules commence in the convoluted part and renal columns as the renal

corpuscles, which are small rounded masses of a deep red colour, varying in size, but of an

average of about 0.2 mm. in diameter. Each of these little bodies is composed of two parts: a

central glomerulus of vessels, and a membranous envelope, the glomerular capsule (capsule

of Bowman), which is the small pouch-like commencement of a renal tubule. 16

The glomerulus is a lobulated network of convoluted capillary blood vessels, held together by

scanty connective tissue. This capillary network is derived from a small arterial twig, the

afferent vessel, which enters the capsule, generally at a point opposite to that at which the

latter is connected with the tubule; and the resulting vein, the efferent vessel, emerges from

the capsule at the same point. The afferent vessel is usually the larger of the two. The

glomerular or Bowman’s capsule, which surrounds the glomerulus, consists of a basement

membrane, lined on its inner surface by a layer of flattened epithelial cells, which are

reflected from the lining membrane on to the glomerulus, at the point of entrance or exit of

the afferent and efferent vessels.16

The renal tubules, commencing in the renal corpuscles, present, during their course, many

changes in shape and direction, and are contained partly in the medullary and partly in the

cortical substance. At their junction with the glomerular capsule, they exhibit a somewhat

constricted portion, which is termed the neck. Beyond this, the tubule becomes convoluted

and pursues a considerable course in the cortical substance constituting the proximal

convoluted tube. After a time, the convolutions disappear, and the tube approaches the

medullary substance in a more or less spiral manner; this section of the tubule has been called

11

the spiral tube. Throughout this portion of their course, the renal tubules are contained

entirely in the cortical substance and present a fairly uniform calibre. They now enter the

medullary substance, suddenly become much smaller, quite straight in direction, and dip

down for a variable depth into the pyramids, constituting the descending limb of Henle’s

loop. Bending on themselves, they form what is termed the loop of Henle, and reascending,

they become suddenly enlarged, forming the ascending limb of Henle’s loop, and re-enter the

cortical substance. This portion of the tubule ascends for a short distance, when it again

becomes dilated, irregular, and angular. This section is termed the zigzag tubule; it ends in a

convoluted tube, which resembles the proximal convoluted tubule, and is called the distal

convoluted tubule. This again terminates in a narrow junctional tube, which enters the

straight or collecting tube. 16

The straight or collecting tubes commence in the radiate part of the cortex, where they

receive the curved ends of the distal convoluted tubules. They unite at short intervals with

one another, the resulting tubes presenting a considerable increase in calibre, so that a series

of comparatively large tubes passes from the bases of the rays into the renal pyramids. In the

medulla, the tubes of each pyramid converge to join a central tube (duct of Bellini) which

finally opens on the summit of one of the papillæ; the contents of the tube are therefore

discharged into one of the calyces.16

Renal blood vessels: Knowledge of some features of the arrangement of blood vessels within

the kidney is essential to the understanding of renal function.17

At the hilum of the kidney each renal artery divides into a number of lobar arteries (one for

each pyramid). Each lobar artery divides into two (or more) interlobar arteries that enter the

tissue of

12

the renal columns and run towards the surface of the kidney. Reaching the level of the bases

of the pyramids, the interlobar arteries divide into arcuate arteries. The arcuate arteries run at

right angles to the parent interlobar arteries.

They lie parallel to the renal surface at the junction of the pyramid and the cortex. They give

off a series of interlobular arteries that run through the cortex at right angles to the renal

surface to end in a subcapsular plexus. Each interlobular artery gives off a series of arterioles

that enter glomeruli as afferent arterioles. Blood from these arterioles circulates through

glomerular capillaries that join to form efferent arterioles that emerge from glomeruli.17

The behaviour of efferent arterioles leaving the glomeruli differs in the case of glomeruli

located more superficially in the cortex, and those lying near the pyramids. Efferent arterioles

arising from the majority of glomeruli (superficial) divide into capillaries that surround the

proximal and distal convoluted tubules. These capillaries drain into interlobular veins, and

through them into arcuate veins and interlobar veins.17

Ureter: The ureters are the two tubes which pass on the urine from the kidneys to the urinary

bladder. Each originates within the sinus of the corresponding kidney as a number of short

cup-shaped tubes, termed calyces, which encircle the renal papillæ. Since a single calyx may

enclose more than one papilla, the calyces are generally fewer in number than the pyramids -

the former varying from 7–13, the latter from 8–18. The calyces join to form 2 or 3 short

tubes, and these unite to form a funnel-shaped dilatation, wide above and narrow below,

named the renal pelvis, which is situated partly inside and partly outside the renal sinus. It is

usually placed on a level with the spinous process of the first lumbar vertebra.16

The Ureter Proper measures 25 to 30 cm in length and is a thick-walled narrow cylindrical

tube which is directly continuous near the lower end of the kidney with the tapering extremity

of the renal pelvis. It runs downward and medialward in front of the psoas major and,

13

entering the pelvic cavity, finally opens into the fundus of the bladder. The abdominal part

(pars abdominalis) lies behind the peritoneum on the medial part of the psoas major and is

crossed obliquely by the internal spermatic vessels. It enters the pelvic cavity by crossing

either the termination of the common or the commencement of the external iliac vessels. 16

The pelvic part (pars pelvina) runs at first downward on the lateral wall of the pelvic cavity

along the anterior border of the greater sciatic notch and under cover of the peritoneum.

Opposite the lower part of the greater sciatic foramen, it inclines medialward and reaches the

lateral angle of the bladder, where it is situated in front of the upper end of the seminal

vesicle and at a distance of about 5 cm from the opposite ureter; here the ductus deferens

crosses to its medial side and the vesical veins surround it. Finally, the ureters run obliquely

for about 2 cm through the wall of the bladder and open by slit-like apertures into the cavity

of the viscus at the lateral angles of the trigone. When the bladder is distended, the openings

of the ureters are about 5 cm apart, but when it is empty and contracted, the distance between

them is diminished by one-half. Owing to their oblique course through the coats of the

bladder, the upper and lower walls of the terminal portions of the ureters become closely

applied to each other when the viscus is distended, and, acting as valves, prevent

regurgitation of urine from the bladder. 16

Urinary bladder: The urinary bladder is a musculomembranous sac which acts as a reservoir

for the urine; and as its size, position, and relations vary according to the amount of fluid it

contains, it is necessary to study it as it appears (a) when empty and (b) when distended). In

both the conditions, the position of the bladder varies with the condition of the rectum, being

pushed upward and forward when the rectum is distended. 16

The empty bladder - When hardened in situ, the empty bladder has the form of a flattened

tetrahedron, with its vertex tilted forward. It presents a fundus, a vertex, a superior, and an

14

inferior surface. The fundus is triangular in shape and is directed downward and backward

toward the rectum, from which it is separated by the rectovesical fascia, the vesiculæ

seminales, and the terminal portions of the ductus deferentes. The vertex is directed forward

toward the upper part of the symphysis pubis, and from it, the middle umbilical ligament is

continued upward on the back of the anterior abdominal wall to the umbilicus. The

peritoneum is carried by it from the vertex of the bladder onto the abdominal wall to form the

middle umbilical fold. The superior surface is triangular, bounded on either side by a lateral

border which separates it from the inferior surface, and behind by a posterior border,

represented by a line joining the two ureters, which intervenes between it and the fundus. The

lateral borders extend from the ureters to the vertex, and from them, the peritoneum is carried

to the walls of the pelvis. On either side of the bladder, the peritoneum shows a depression

named the paravesical fossa. The superior surface is directed upward, is covered by

peritoneum, and is in relation with the sigmoid colon and some of the coils of the small

intestine. 16

The inferior surface is directed downward and is uncovered by peritoneum. It may be divided

into a posterior or prostatic area and two inferolateral surfaces. The prostatic area is

somewhat triangular: it rests upon and is in direct continuity with the base of the prostate and

from it the urethra emerges.

The distended bladder - When the bladder is moderately full, it contains about 0.5 L and

assumes an oval form; the long diameter of the oval measures about 12 cm and is directed

upward and forward. In this condition, it presents a posterosuperior, an anteroinferior, and

two lateral surfaces, a fundus and a summit. The posterosuperior surface is directed upward

and backward, and is covered by peritoneum: behind, it is separated from the rectum by the

rectovesical excavation, while its anterior part is in contact with the coils of the small

intestine.16

15

Urethra: The male urethra extends from the internal urethral orifice in the urinary bladder to

the external urethral orifice at the end of the penis. It presents a double curve in the ordinary

relaxed state of the penis. Its length varies from 17.5 to 20 cm and it is divided into 3

portions, the prostatic, membranous, and cavernous, the structure and relations of which are

essentially different. Except during the passage of the urine or semen, the greater part of the

urethral canal is a mere transverse cleft or slit, with its upper and under surfaces in contact; at

the external orifice the slit is vertical, in the membranous portion irregular or stellate, and in

the prostatic portion somewhat arched.

The female urethra is a narrow membranous canal, about 4 cm. long, extending from the

internal to the external urethral orifice. It is placed behind the symphysis pubis, imbedded in

the anterior wall of the vagina, and its direction is obliquely downward and forward; it is

slightly curved with the concavity directed forward. Its diameter when undilated is about 6

mm. It perforates the fasciæ of the urogenital diaphragm, and its external orifice is situated

directly in front of the vaginal opening and about 2.5 cm behind the glans clitoridis. The

lining membrane is thrown into longitudinal folds, one of which, placed along the floor of the

canal, is termed the urethral crest. Many small urethral glands open into the urethra. 16

Prostate: The prostate is a firm, partly glandular and partly muscular body, which is placed

immediately below the internal urethral orifice and around the commencement of the urethra.

It is situated in the pelvic cavity, below the lower part of the symphysis pubis, above the

superior fascia of the urogenital diaphragm, and in front of the rectum, through which it may

be distinctly felt, especially when enlarged. It is about the size of a chestnut and somewhat

conical in shape, and presents for examination a base, an apex, an anterior, a posterior and

two lateral surfaces. The base (basis prostate) is directed upward, and is applied to the inferior

surface of the bladder. The greater part of this surface is directly continuous with the bladder

wall; the urethra penetrates it nearer its anterior than its posterior border. The apex

16

(apex prostate) is directed downward, and is in contact with the superior fascia of the

urogenital diaphragm. 16

Evaluation of hematuria

Evaluation starts with a complete patient history which includes (hereditary renal disease like

Alport's syndrome and polycystic kidney disease) and infection (including Mycobacteria and

Schistosoma), physical examination, laboratory work, and radiological imaging.18

After

completing a complete history and physical examination, patients without obvious mimics of

hematuria require further evaluation.6 Early and accurate diagnosis of etiological factor helps

in early and effective management.1

Evaluation of microscopic hematuria

The criteria used to diagnose nonvisible hematuria and for referral to a nephrologist or

urologist vary widely.19

Nonvisible hematuria can be detected on a chemical dipstick or

microscopy. Hemoglobin, either free in the urine or within urinary Red Blood Cells (RBCs),

catalyzes the oxidation of substances on a chemical dipstick, resulting in a change of colour

that indicates hematuria. Urinary dipsticks are useful for detecting nonvisible hematuria, with

a sensitivity of 91–100%, but they have a low specificity, ranging from 65–99%.20

Current standard of care for patients with asymptomatic nonvisible hematuria is to undergo

urinalysis on at least 2 separate occasions, whereas those with symptomatic nonvisible

hematuria or visible hematuria are referred immediately after 1 positive urinalysis and

exclusion of transient causes of hematuria and UTI. The next step is to determine whether

referral to a urologist or nephrologist is most appropriate based on the results of renal

function tests, and to determine if the hematuria originates in the nephron (glomerular or

tubular) or from the epithelium.21

Hypercalciuria is a common cause of microhematuria and

it can lead to gross hematuria.22

17

Imaging investigations for patients with hematuria are usually performed to diagnose any

serious underlying upper urinary tract disease, such as stones, renal cell cancer or Upper

Urinary Tract Urothelial Cell Carcinoma (UUT-UCC). Traditionally, Intravenous Urography

(IVU) and ultrasonography were the imaging techniques preferred for the initial

investigation.21

Evaluation of macroscopic hematuria

Gross hematuria, or macroscopic hematuria, is defined as blood that can be seen with the

naked eye. Patients are often distraught when it presents and seek medical care immediately.

It is a common complaint in children. The evaluation of gross hematuria is started by

evaluating the source of bleeding that can originate from the glomerulus and interstitium, the

urinary tract, or renal vasculature.22

Physical examination:

The physician should do a careful abdominal examination to look for abdominal or flank

masses. Suprapubic pain may isolate the source of bleeding and indicate possible infection,

stone, or other bladder pathology. Blood pressure measurement should be performed to look

for hypertension and may indicate glomerulonephritis or renal insufficiency, especially in the

presence of edema. Presence of pallor, fever, skin rashes or musculoskeletal findings may

give clues to systemic disease, such as systemic lupus erythematosus with glomerulonephritis

22

Laboratory tests:

Microscopic examination of the urine should be performed to confirm the presence of RBCs.

If absent, myoglobinuria, haemoglobinuria, or other substances (eg, medications or food

substances) should be considered. Plasma proteins are excreted in proportion to the degree of

bleeding, and gross hematuria from lower urinary tract bleeding often only gives rise to 2+

18

proteinuria by dipstick reading. Anything more than 2+ protein, glomerular disease should be

suspected. Bacteria and significant pyuria may indicate pyelonephritis or cystitis.22

Further inspection of the erythrocyte morphology may provide insight into the origin of the

bleeding. Size, shape, and hemoglobin content can help differentiate the source of

erythrocytes. Small, dysmorphic, or crenated cells with low hemoglobin content (pale cells)

are believed to originate from the glomerulus, whereas normal-shaped and sized cells

originate from the urinary tract outside the glomerulus. This examination is best done with a

phase contrast microscope.22

Additional laboratory testing is dictated by the suspected source of bleeding and patient

symptoms and history. All patients with suspected glomerulonephritis should have an

assessment of their renal function (serum creatinine) and a complete blood count. Gross

hematuria also can be seen with nonbacterial infections, such as tuberculosis, adenovirus, and

schistosomiasis.22

Radiologic imaging and cystoscopy:

Renal imaging with non-invasive ultrasonography is recommended to investigate urologic

disease or congenital abnormalities but also can give firm evidence for renal parenchymal

disease.22

Patients with gross hematuria were more likely to undergo upper tract imaging.23

Cystograms generally play no greater role in the evaluation of gross hematuria unless there is

suspicion of bladder outlet obstruction from an unusual mass, such as a urothelial tumor,

rhabdomyosarcoma, or fibromatous polyp. CT imaging is used to identify kidney stones

(using helical technique) and provides detailed images of the bladder, pelvis, and

retroperitoneum when looking for masses.22

19

Radiological evaluation of hematuria.

Radiologic imaging plays a pivotal role in the diagnosis of hematuria. There are various

imaging modalities used in evaluation of hematuria that can be used to image the urinary

tract. There are various imaging modalities used in evaluation of hematuria that can be used

to image the urinary tract. Generally, these imaging modalities allow for diagnosis of upper

urinary tract (kidney and ureter) pathology, whereas lower urinary tract (bladder and urethra)

pathology is diagnosed via direct visualization with cystoscopy.6

The primary role of imaging is to identify those patients with a malignant cause of

hematuria.11

Until the beginning of the 21st century, IVU and ultrasound were the initial

radiological methods for genitourinary imaging.21

Currently no imaging modality is

sufficiently sensitive for the detection of urothelial carcinoma of the bladder, and cystoscopic

evaluation of the lower urinary tract is essential in the complete evaluation of hematuria.11

The choice of modality to image the upper urinary tract will depend on individual patient

factors such as age, the presence of risk factors for malignancy, renal function, a history of

calculus disease and pregnancy, and other factors, such as local policy and practice, cost

effectiveness, and availability of resources.11

Many imaging modalities have been used in the

evaluation of patients with hematuria.13

First-line investigations often include conventional

radiography, renal ultrasound, and/or IVU in combination with cystoscopy. Second-line

investigations include MDCTU and MRU, often only carried out if the first-line tests reveal

an abnormality.11

MDCTU is the most sensitive and specific test for the diagnosis of urinary

tract calculi and for detecting and characterizing renal masses.11

The term CTU is often used in clinical practice for a huge number of MDCT techniques for

evaluating the urinary tract. CTU is defined as a diagnostic examination optimized for

imaging of the kidneys, ureters, and bladder.24

20

The different types of radiological modalities are presented below:

Abdominal radiographs

The role of the plain abdominal radiograph in hematuria is very limited. Recent large studies

on the effect of imaging modalities in the acute abdomen radiography showed virtually no

additional value in diagnosis. Its overall sensitivity for renal and ureteral stones is only 45–

60% in multiple studies. 8

Ultrasound

Ultrasound is suitable as only first-line diagnostic test, especially in young patients with

nonurologic diseases. A large study showed that it has a high specificity but moderate

sensitivity for the diagnosis of bladder tumors. Ultrasound alone is not sensitive (19–32%)

for stone detection. 8

Combined radiograph and ultrasound

The combination is inferior to unenhanced CT for stone disease but does not miss significant

disease. Studies found sensitivities of 77–79%, with negative predictive values of 46–68%.

The role of contrast-enhanced ultrasound is not yet well defined. 8

Excretory urography

Excretory urography has long been the cornerstone for evaluation of the upper urinary tract.

For hematuria, multiple studies have now shown the superiority of CT urography over

excretory urography. There is also a low sensitivity (< 60%) for renal tumors smaller than 3

cm for excretory urography.8

21

Retrograde ureteropyelography

Invasive retrograde ureteropyelography can be used for more detailed characterization of

filling defects and other pathologic findings of the pyelocalyceal systems. In the time of

excretory urography, retrograde ureteropyelography was used in patients with limited

opacification of the upper urinary tracts, such as in patients with obesity or decreased renal

function. However, with the increasing use of MDCT urography and ureterorenoscopy, its

role has decreased significantly. It has been shown that, in high-risk patients, CTU is

equivalent to retrograde ureteropyelography in the upper urinary tract, so that retrograde

ureteropyelography is used only as a second or third-line imaging modality of the upper

urinary tracts when ultrasound or CT urography findings are negative and hematuria persists

or in case of an afunctional kidney.8

MDCT-A choice for evaluation of the kidney and urinary tract.

Multidetector CT (MDCT, multislice CT, multidetector-row CT, multisection CT) represents

a breakthrough in CT technology. It has transformed CT from a transaxial cross-sectional

technique into a true 3D imaging modality that allows for arbitrary cut planes as well as

excellent 3D displays of the data volume.25

MDCTU is emerging as the imaging modality of choice. It is rapidly becoming acceptable as

the preferred test for diagnosing urinary tract disease responsible for hematuria because of

superior spatial resolution, higher speed, isotropic reconstruction capability, excellent 3D

multiplanar reformats and depiction of entire urinary tract in single breath-hold examination.1

One of the main advantages of MDCTU in the evaluation of the urinary tract for causes of

hematuria, is its ability to display the entire urinary tract, including renal parenchyma,

pelvicalyceal systems, ureters and the bladder using a single imaging test.5 MDCTU is a

versatile imaging test, which can clearly demonstrate urinary tract anomalies, inflammatory

22

processes, calculus diseases, and benign and malignant neoplasms. Consequently, it is being

increasingly recommended as a first line of investigation in the patients with hematuria.5 The

superior diagnostic performance of MDCTU over IVU in the detection of malignancy,

combined with recent advances in dose reduction and a wider availability of the technique,

has led many authors to recommend MDCTU as a first-line modality to image the upper

urinary tract in patients with hematuria.11

Clinical applications:

MDCT imaging has its applications in following

Liver transplantation

Hepatic resection

Pancreaticobiliary imaging

Urinary tract

Gastrointestinal tract26

ADVANTAGES:

It is rapidly becoming acceptable as the preferred test for diagnosing urinary tract disease

responsible for hematuria because of its

Superior spatial resolution

Higher speed

Isotropic and reconstruction capability

Excellent 3D multiplanar reformats

Depiction of entire urinary tract in single breath hold examination18

23

DISADVANTAGES:

From a practical standpoint, developments in MDCT scanning allow multiple thin slices

to be acquired with increased z-axis coverage in a single breath-hold, which generates an

extraordinary increase in the quantity of acquired data

Review of an enormous number of images causes significant restraints on radiologists’

efficiency and may be simply impractical

Moreover, the sheer number of images raises additional problems and expense for those

departments, which have not yet converted to PACS and still use film for reading

However, this approach will need thorough investigation and comparison to conventional

CT practices before it can be widely embraced26

Urolithiasis

Urinary tract calculus is common cause of haematuria. MDCTU accurately detects it on the

initial unenhanced study5 mainly in non-obstructive calculus. Excretory urography can be

used, some reports suggest that it fails to demonstrate calculi in up to 48% of cases27,28

.

Although conventional radiography may help detect urinary calculi, it is not as sensitive as

unenhanced CT29

. US is also useful in detecting renal calculi and may demonstrate

hydronephrosis due to obstructing ureteral calculi but often does not allow direct visualization

of ureteral calculi.

Nearly all stones, including those containing uric acid and those located in unusual positions

such as caliceal diverticulum are detectable by CT. An unenhanced study is highly sensitive

and accurate in diagnosing obstruction secondary to ureteric calculi5, in demonstrating size

and location of urinary tract calculi.

The secondary signs which can be used for confirmation of diagnosis are-

24

1."Soft tissue rim sign"- a circumferential rim of soft-tissue attenuation surrounding the

calcification, is a strong indicator that a calcification along the course of the ureter is a

calculus30

.

2."Comet-tail sign"- representing a linear or curvilinear soft-tissue structure extending from a

calcification, is an important indicator that a suspicious calcification represents a phlebolith,

while its absence suggests indeterminate calcification31

.

Role of urographic images in identification of calculus is limited as an opacified ureter may

hide calculi. Use of bone window increases the conspicuity of urinary tract calcifications and

improves the detection of urinary tract filling defects5.

Urinary Tract Neoplasms

TCC is the commonest malignant neoplasm of the urothelium. Risk factors being exposure to

aniline dyes, phenacetin, tobacco, and prior radiation therapy. Squamous cell carcinoma and

adenocarcinoma are less common bladder neoplasms.

It is now believed that adequate distension and opacification of the ureter, pelvicaliceal

system and bladder are necessary in the thorough evaluation of the urothelium.

BLADDER TUMORS-

CT, USG, cystography, IVU and MR imaging can be used to evaluate the bladder. It has been

reported in literature that excretory urography has detection rates for urothelial neoplasms of only

43-64%32

. Virtual CT cystoscopy is also evolving with sensitivities of 90% reported for bladder

lesions seen by cystoscopy33

. In study done by Kim et al. reported sensitivity and specificity of

95% and 87% of virtual cystoscopy for identifying bladder lesions34

. It also aids in planning of

cystoscopy, cystoscopic resection of bladder tumors and follow-up of patients

25

following cytoscopic resection of polypoidal tumors thus reducing the costs and morbidity

associated with conventional cytoscopy29

IMAGING FEATURES ON MDCTU

Unenhanced study is useful in detection of areas calcification and focal thickening of bladder

wall. Focal bladder wall calcification can occur with TCC or squamous cell carcinoma of the

bladder5.

Post contrast enhancement of focal wall thickening suggest carcinoma5.

Urography phases with fully distended contrast-filled bladder may demonstrate these tumours

as filling defects5.

URETER TUMORS

Traditionally, ureteral disease has been evaluated with IVU or retrograde urethrography.

However, these examinations only demonstrate the lumen of the ureter and do not allow

direct visualization of extrinsic abnormalities that involve the ureter29

.

In the early stages, these neoplasms are seen as subtle filling defects or focal mural

thickening5.

Adequate distension and opacification of the ureter and viewing at bone window aids in

identifying subtle filling defects and in distinguishing ureteral neoplasms from other filling

defects. Multi-planar reconstructions of ureters provide anatomic views of the urinary tract

similar to excretory urography but with surrounding anatomical details. It also demonstrates

the longitudinal extension of a lesion, and can evaluate for the presence of multicentric

tumors5.

26

Advantages of MDCTU over IVU in evaluation of ureters are-

1.Ability to evaluate the ureter distal to an obstructing lesion35

.

2. Identification and characterization of the causes of ureteric obstruction

a. Both benign and malignant strictures with associated mural thickening.

b. Identification of retroperitoneal masses and lymphadenopathy, retroperitoneal

fibrosis. c.Iatrogenic causes such as post hysterectomy and colectomy injuries36

.

RENAL TUMORS

CT has been shown to be more accurate in the detection of parenchymal neoplasms as

compared to USG or excretory urography with sensitivities of 94% reported compared to

67% and 79% for excretory urography and ultrasound respectively37

. CT can detect up to

47% of masses measuring 5mm and 75% of masses measuring 10-15 mm in diameter38

.

IMAGING CHARACTERISATION-

CT imaging helps characterise the renal masses as a simple cyst, a complex cyst, or a solid

mass. Simple cysts are benign, whereas solid masses with the exception of

angiomyolipoma’s, are presumed to be malignant and usually require surgery29

.

A renal cyst must be evaluated according to the wall thickness, presence and thickness of

septa, calcifications, attenuation of the cyst, and foci of enhancement. The Bosniak

classification system29

helps in distinction of benign cystic lesions and cystic neoplasms, and

guides the management of cystic renal masses.

1. Category I -lesions are simple cysts.

27

2. Category II -lesions are slightly more complicated with a size<3cm and may contain a few

thin septa(<1mm), thin calcifications, or non-enhancing high-attenuation fluid (protein or

haemorrhage).

3. Category IIF-intermediate between II and III with hyperdense cyst >3cm with minimal

wall thickening no measurable wall enhancement.

3. Category III- lesions are still more complex and show nodular enhancing wall or septal

thickening.

4. Category IV –cyst with enhancing solid component.

Category I and II are benign no need of follow up or surgery, whereas category III and IV are

possibly malignant and warrant surgery.

Category IIF lesions warrant close follow-up39

. Thin section acquisition combined with thin

reformatting can reduce40

the effect of volume averaging and allow more accurate

Hounsfield values to be calculated, thus reducing the likelihood of pseudo enhancement.

The best phase is the nephrographic phase41,42

for characterization of masses. Although US

is also excellent for characterisation renal masses, it is less sensitive because some lesions are

isoechoic to normal renal parenchyma29

. Limitation of MR is it does not clearly demonstrate

calcification in these masses.

28

Figure 3. Bosniak classification of renal cysts

Urinary Tract Infections

Uncomplicated UTI’s are adequately diagnosed by microbiologic analysis of the urine and

can be managed without cross-sectional imaging43

. Indication for MDCTU is severe sepsis

with accompanying pyuria for exclusion of pyonephrosis or renal abscess. Nephrographic

phase demonstrates the parenchymal abnormalities while excretory phase is better for

diagnosing renal abscesses44

.

Features of acute pyelonephritis are-

1. "Striated nephrogram" in a swollen kidney and stranding of the perinephric fat5.

2. Enhancing wall thickening of the pelvis45

.

3. Solitary or multiple hypodense areas with loss of normal corticomedullary

differentiation.

29

4. Gas within the intrarenal collections or pelvicalyceal system.

Xanthogranulomatous pyelonephritis is a severe form of renal infection associated with long-

term renal obstruction and infection. A large staghorn calculus is usually demonstrated within

the collecting system5.

CLINICAL EVIDENCE -MDCT

Rathi V et al conducted prospective study to assess the role of MDCTU in detecting the

entire spectrum of urinary tract diseases causing hematuria and also to establish whether this

single investigation suffices in directing the right management strategy in all these patients.

Study involved 105 patients with hematuria. 2

Tyagi N et al performed a prospective observational study in which they included a total of

31 patients who presented with painless hematuria referred for CTU. Majority of the patients

were in the age group of 51–60 years, that is 15 (48.38%) cases, followed by 60–70 years,

i.e., 9 (29%), and 41–50 years in 3 (9.7%). The oldest patient was 82 years of age and

youngest was 2 years of age. Male predominance was noted with male: female ratio of 2:1.

17 18

16

12

14

12

10

No. of cases

8

6

2

4

2

0

Kidney

Bladder

Prostate

Graph 1. Distribution of causes of painless hematuria on the basis of site

30

60.00% 54.83% 50.00%

40.00%

38.70%

30.00%

Percentage

20.00% 6.47% 10.00%

0.00%

Kidney Bladder Prostate

Graph 2. Bar chart showing percentage of causes of painless hematuria on the basis of

site.

In their study, they found that MDCTU is considered as the first-line imaging modality for

detection of neoplastic masses in patients with painless heamaturia with high sensitivity and

specificity. It may also be useful in both tumor detection and extraordinary staging in

urothelial carcinoma.18

Kadam SM et al conducted prospective study to evaluate the role of MDCTU in detecting

urinary tract pathologies causing hematuria. Study involved 50 patients with hematuria; 38

(76%) were male and 12 (24%) were female. The findings of MDCT urography were normal

in 8% and abnormal in 92% of patients. The various pathologies causing hematuria are

described in Table 1. Study found that MDCTU had positive findings with concerning high

percentage of identifying pathological findings (sensitivity 92% and positive predictive value

of 100%) among patients with hematuria. The male: female ratio was found to be almost

about 3:1.1

31

Table 3. MDCT Urography findings among patients with hematuria1

Pathologies on MDCTU Total no. of patients n (%) Male Female

Urolithiasis 20 (40%) 12 8

Benign prostatic hyperplasia 7 (14%) 7 1

Carcinoma of bladder 6 (12%) 5 1

Renal infection 6 (12%) 4 2

CA prostate 3 (6%) 3 -

Renal neoplasm 2 (4%) 2 -

Trauma 2 (4%) 2 -

Mahmoud MA et al conducted a prospective cohort study to discuss and illustrate the role of

MDCTU, on a 32-row CT scanner in the evaluation of a variety of entities that were

frequently associated with microscopic hematuria in adults. The study included 50 positive

participants. MDCTU ascertained the correct cause of microscopic hematuria in 44 (88%) of

participants. The causes of hematuria in 41 (82%) participants were diseases in the upper

urinary tract, while

urinary bladder neoplasms (2; 4%) and diverticulum (1; 2%) were the causes of hematuria (3;

6%) in the lower urinary tract.13

Dr. Dipika AJ and Dr. Dharita S. Shah performed a prospective study of 100 patients with

urinary symptomatology who presented at VS Hospital Ahmedabad during the period from

August 2015 to May 2016 to identify the importance of CTU in detecting all types of stones,

32

neoplasms, obstructions, congenital anomalies, and other pathologies in hematuria. In this

particular study, they analyzed 100 patients of which 68 were male and 32 were female and

the the most common age group was 41–60 years. 45

Obstructive

No. of cases

Neoplastic

5 3

Infective

6

Post-operative/Post

6

intervention

7 50

Congenital

9

Urinary bladder pathologies

14

Renal cystic disease

Extra-urinary

Graph 3. Of the 100 patients, the distribution of various etiologies is as follows45

MA Karthikeyan and Poonam Vohra conducted a cross-sectional observational study in 35

patients and out of 35 patients included in the study, 23 (65.71%) were males and 12

(34.28%) were females with a Male:Female ratio of 1.91:1. Age of the patients included in

their study ranged from 2–85 years with a mean age of 46.8 years. MDCT is the imaging

modality of choice for further evaluation and characterization. CT is done in 4 phases viz.,

unenhanced, corticomedullary, nephrographic, and excretory phase especially in cases of

malignancy; while in benign conditions like angiomyolipoma and abscess, evaluation with

unenhanced and single-phase post contrast in portovenous phase is sufficient.46

Rheaume-

Lanoie et al performed retrospective study which was approved by their institutional review

board. In that study, they evaluated the diagnostic performance of ultrasound for detecting

urinary tract neoplasm in the setting of macroscopic hematuria by using MDCTU and

cystoscopy as the reference standard. A total of 17 urinary tract

33

neoplasms were proven by pathologic evaluation: 14 transitional cell carcinoma and 3 renal cell

carcinomas.47

Hematuria is defined as the presence of blood in urine and is one of the most common

manifestations of urinary tract disease and can be painless or painful. Malignancies are the most

common cause of painless hematuria. The aim of the present study is to evaluate the role of

MDCT in patients with hematuria and to study the MDCT features of various common etiologies

causing it. Also studying about the different imaging modalities for specificity and sensitivity in

imaging the hematuria and highlighting the use of MDCT urography in detection of hematuria.

34

MATERIALS AND METHODS

STUDY POPULATION-

• Patients with history of hematuria, between 17-75 years were subjected to study

which includes out patients, inpatients, referral patients of Vydehi instiute of medical

science and research Centre, Bangalore.

METHOD OF COLLECTION OF DATA-

A prospective study was conducted on 45 patients who presented with haematuria to the OPD

and were suspected to have a urological cause were referred to the Department of

Radiodiagnosis in our hospital in a period of 1.5 years ranging from January 2016 to June

2017.

INCLUSION CRITERIA

1. Patients presenting with hematuria referred to department of radiodiagnosis.

EXCLUSION CRITERIA

1. Patients below 17 and above 75 years of age.

2. Severe renal failure

3. Cardiac failure

4. Previous allergic reaction to contrast media

5. Patients with non-urologic causes of hematuria

6. Pregnant and lactating patient

7. Multiple myeloma

Informed consent was taken from all the patients included in the study and the study was

conducted after approval by the ethics committee.

36

Data acquisition and analysis:

Examination Technique

All Multiphasic examinations will be performed with a 128 slice Somatom Definition AS.

CT scans will be obtained from the diaphragm to the bladder with the following technique: a

collimator of 5 mm, a pitch of 1.5/2, and with150- 200 mAs, KV 100.Unenhanced CT of the

abdomen and pelvis was performed after which the corticomedullary phase is acquired following a

delay of 25-80 seconds after administration of 80 ml (rate of 3.5ml/sec) of intravenous non-ionic

low osmolar contrast medium (lohexol)using a power injector ,mainly to differentiate normal

variants of renal parenchyma from renal masses. This is followed by neprographic phase, after

delay of 90- 100 seconds following contrast administration to evaluate the renal parenchyma and

the last phase pyelography phase is taken after 8-10 minutes post IV contrast administration, to

evaluate the urothelial.

Figure 4: 16-channel MDCT scanner (GE LightSpeed RT) at VIMS & RC

37

Patient preparation:

1. All the patients were instructed to come with empty stomach on the day of procedure.

2. Renal functional status of all patients was noted before undergoing contrast CT.

3. All patient’s clinical history was elicited to rule out previous contrast reactions/allergies.

Image interpretation:

Interpretation of the CT images will be performed on a workstation equipped with a

software tool, which allows generation of maximum intensity projections (MIPs), volume

renderings (VRs), and multiplanar reconstructions (MPRs). The reconstructed images are

evaluated for the level and cause of obstruction. Combined interpretation of the images in

unenhanced, hepatic arterial dominant and portal venous dominant phase will be performed.

All the cases were comprehensively evaluated and correlated with relevant history and

clinical examination. The final diagnosis will be established after correlation with histopathologic

findings or the findings at a urologic procedure (cystoscopy, ureteroscopy and retrograde

pyelography) wherever possible.

38

STATISTICAL ANALYSIS

Data was entered into Microsoft excel data sheet and was analysed using SPSS 22 version

software. Categorical data was represented in the form of Frequencies and proportions. Chi-

square test or Fischer’s exact test (for 2x2 tables only) was used as test of significance for

qualitative data.

Graphical representation of data: MS Excel and MS word was used to obtain various types

of graphs

P value (Probability that the result is true) of <0.05 was considered as statistically significant

after assuming all the rules of statistical tests.

Statistical software: MS Excel, SPSS version 22 (IBM SPSS Statistics, Somers NY, USA)

was used to analyse data

Age distribution, gender distribution, type of hematuria, causes of hematuria, distribution

of causes according to the location and imaging features of kidney and urinary tract

neoplasms were described as frequency and percentage

39

SAMPLE SIZE-

The sample size for the study is 45 patients.

INCLUSION CRITERIA

1. Patients presenting with hematuria referred to department of radiodiagnosis.

EXCLUSION CRITERIA

1. Patients below 17 and above 75 years of age.

2. Severe renal failure

3. Cardiac failure

4. Previous allergic reaction to contrast media

5. Patients with non-urologic causes of hematuria

6. Pregnant and lactating patient

7. Multiple myeloma

OBSERVATION & RESULTS

Table 4: - Distribution of the subjects according age group

Age group Frequency Percent

10-19yrs 1 2.2

20-29yrs 8 17.8

30-39yrs 2 4.4

40-49yrs 13 28.9

50-59yrs 11 24.4

60yr and above 10 22.2

Total 45 100.0

Majority of the subjects 28.9% were in 40-49yrs age group followed by 24.4% were in 50-

59yrs age group, 22.2% were in 60yrs and more age group, 17.8% were in 20-29yrs age

group, 4.4% were in 30-39yrs age group and only 2.2% were in 10-19yrs age group

Graph 4: - Graph showing Distribution of the subjects according age group

40

Table 5: - Distribution of the subjects according sex

Sex Frequency Percent

Female 15 33.3

Male 30 66.7

Total 45 100.0

Majority of the subjects 66.7% were male and 33.3% were female

Distrubution according to Sex

33% Female

Male

67%

Graph 5: - Graph showing Distribution of the subjects according sex

41

Table 6: - Distribution of the subjects according Haematuria

Haematuria Frequency Percent

Macro 38 84.4

Micro 7 15.6

Total 45 100.0

Majority of the subjects 84.4% had Macro Haematuria and 15.6% had Micro Haematuria.

Distrubution according to Haematuria

16%

Macro

Micro

84%

Graph 6: - Graph showing Distribution of the subjects according Haematuria

42

Table 7: - Distribution of the subjects according symptoms

Frequency Percent

Present 12 26.7

Absent 33 73.3

Total 45 100.0

Majority of the subjects 73.3% had Haematuria without symptoms and 26.7%

had Haematuria with symptoms.

Distrubution according to symptoms

27%

Present Absent

73%

Graph 7: - Graph showing Distribution of the subjects according symptoms

43

Table 8: - Distribution of the subjects according causes of Haematuria

Frequency Percent

Calculi 11 24.4

Infec tion 3 6.7

Bladder Ca 17 37.8

Renal Ca 8 17.8

Ureter Ca 2 4.4

Trauma 4 8.9

Total 45 100.0

Majority of the subjects 37.8% had Bladder Carcinoma followed by 24.4% of the subjects

had Calculi, 17.8% had renal carcinoma, 8.9% had trauma, 6.7% had infection and 4.4%

had ureter Carcinoma.

Graph 8: - Graph showing Distribution of the subjects according causes of Haematuria

44

Table 9: - Distribution of the subjects according causes of Haematuria and type of

haematuria

HEMATURIA Total

Macro Micro

Calculi

9 2 11

81.8% 18.2% 100.0%

Infec tion

0 3 3

.0% 100.0% 100.0%

Bladder carcinoma

17 0 17

100.0% .0% 100.0%

Renal carcinom a

7 1 8

87.5% 12.5% 100.0%

Ureter carcinoma

2 0 2

100.0% .0% 100.0%

Trauma

3 1 4

75.0% 25.0% 100.0%

Total

38 7 45

84.4% 15.6% 100.0%

Among the subject who had calculi as cause for haematuria 81.8% of subject had macro

haematuria and 18.2% had Micro haematuria. All the subjects who had infection had micro

haematuria. Majority of the subjects with neoplasm had macro haematuria. Among the

subject who had Trauma as cause for haematuria 75% of subject had macro haematuria and

25% had Micro haematuria.

P value 0.001, there was a statistically significant difference between Causes and type

of haematuria

45

per

cen

tage

MACRO MICRO 100

90

80

70

60

50

40

30

20

10

0 Calculi Infection Bladder Ca Renal Ca Ureter Ca Trauma

Graph 9: - Graph showing Distribution of the subjects according causes of

Haematuria and type of haematuria

46

Table 10: - Distribution of the subjects according causes of Haematuria and type of

haematuria

HEMATURIA

Total

With symptoms Without

symptoms

Calculi 3 8 11

27.3% 72.7% 100.0%

Infec tion 1 2 3

33.3% 66.7% 100.0%

Bladder carcinoma 4 13 17

23.5% 76.5% 100.0%

Renal carcinom a 1 7 8

12.5% 87.5% 100.0%

Ureter carcinoma 1 1 2

50.0% 50.0% 100.0%

Trauma 2 2 4

50.0% 50.0% 100.0%

Total 12 33 45

26.7% 73.3% 100.0%

Among the subject who had calculi as cause for haematuria 72.7% had haematuria without

symptoms. Among the subject who had infection as cause for haematuria 33.3% of subject

had haematuria with symptoms. Majority of the subjects who had carcinoma as cause for

haematuria had haematuria without symptoms.

P value 0.754, there was no statistically significant difference between symptoms and type of

haematuria

47

percen

tag

e

100

90 With Symptoms

80 Without Symptoms

70

60

50

40

30

20

10

0

Calculi Infection Bladder Ca Renal Ca Ureter Ca Trauma

Graph 10: - Graph showing Distribution of the subjects according causes

of Haematuria and type of haematuria

48

Table 11: - Distribution of the subjects according symptoms and type of haematuria

Symptom s HEMATURIA Total

Macro Micro

Present 10 2 12

26.3% 28.6% 26.7%

Absent 28 5 33

73.7% 71.4% 73.3%

Total 38 7 45

100.0% 100.0% 100.0%

26.3% of the subject who had Macro haematuria had symptoms and 73.7% did not had

symptoms. 28.6% of the subject who had Micro haematuria had symptoms and 71.4% did not

had symptoms

P Value 0.901, there was no statistically significant difference found between symptoms and

type of haematuria

100

With Symptoms

Without Symptoms

90

80

70

60

50

40

30

20

10

0

MACRO

MICRO

Graph 11: - Graph showing Distribution of the subjects according symptoms and

type of haematuria

49

Table 12: - Distribution of calculi according location

CAL CU LI No of subjects %

Renal 4 36.36

Ureteric 6 54.54

Vesical 1 9.10

Total 11 100

Majority of the subjects who had calculi 54.54% had calculi in ureteric followed by renal

in 36.36% and vesical in 9.10%

Distrubution according to location

9%

36% Renal

Ureteric

Vesical

55%

Graph 12: - Graph showing Distribution of calculi according location

50

Table 13: - Distribution of Features of Renal Carcinoma

Renal carcinoma No of subjects %

Enhance ment 8 100

Necrosis 4 50

Haemorrhage 0 0

Calcif icat ion 2 25

Lymphadenopathy 6 75

Renal vein invas ion 3 37.5

IVC invas ion 0 0

Distant metas tasis 4 50

Distant metastasis

IVC invasion

Renal vein invasion

Lymphadenopathy

Calcification

Haemorrhage

Necrosis

Enhancement

0 20 40 60 80 100 Percentage

Graph 13: - Graph Showing Distribution of Features of Renal Carcinoma

51

Table 14: - Distribution of Features of bladder Carcinoma

Bladder Carcinoma N %

Enhance ment 17 100

Growth pattern

Papil lary 11 64.70

Sessile 3 17.64

Calcification 2 11.76

VUJ invasion 8 47.05

Hydroureteronephrosis 8 47.05

Focal wall thickening 2 11.76

Local infilt ration 6 35.29

Distant metas tasis 0 0

Graph 14: - Graph Showing Distribution of Features of Bladder Carcinoma

52

Table 15: - Distribution of subjects according age group and cause of haematuria

AGE GRO UP Bladder Ca Calculi Infection Renal Ca Trauma Ureter Ca

10-19yrs 0 0 0 0 1 0

.0% .0% .0% .0% 25.0% .0%

20-29yrs 1 2 2 1 2 0

5.9% 18.2% 66.7% 12.5% 50.0% .0%

30-39yrs 0 0 0 2 0 0

.0% .0% .0% 25.0% .0% .0%

40-49yrs 5 5 1 2 0 0

29.4% 45.5% 33.3% 25.0% .0% .0%

50-59yrs 6 3 0 1 0 1

35.3% 27.3% .0% 12.5% .0% 50.0%

60yrs and above 5 1 0 2 1 1

29.4% 9.1% .0% 25.0% 25.0% 50.0%

Total 17 11 3 8 4 2

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% Among the subject who had bladder carcinoma 35.3% were in 50-59yrs, 29.4% in 40-49yrs

and 60 and above each, 5.9% in 20-29yrs age group.

Among the subject who had renal carcinoma 33.3% were in 40-49yrs and 66.7% in 20-29yrs

age group. Among the subject who had ureter carcinoma 50% were in 50-59yrs and 50% in

60yrs and above age group. Among the subject who had calculi 45.5% were in 40-49yrs,

27.3% in 50-59yrs, 18.2% in 20-29yrs age group and 9.1% in 60yrs and above age group.

Among the subject who had trauma 50% were in 20-29yrs and 25% each in10-19yrs and 60yrs

and above age group.

P Value 0.061, there was no statistically significant difference found between age group and

cause of haematuria

53

percen

tag

e

100

10-19YRS

20-29YRS

90

30-39YRS

40-49YRS

50-59YRS

60 AND MORE 80

70

60

50

40

30

20

10

0

Calculi Infection Bladder Ca Renal Ca Ureter CaTrauma

Graph 15: - Graph showing Distribution of subjects according age group and cause of

haematuria

54

Table 16: - Distribution of subjects according sex and cause of haematuria

Sex Bladder Ca Calculi Infection Renal Ca Trauma Ureter Ca

Male 15 7 2 4 0 0

88.2% 63.6% 66.7% 50.0% .0% .0%

Female 2 4 1 4 4 2

11.8% 36.4% 33.3% 50.0% 100.0% 100.0%

Total 17 11 3 8 4 2

100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Among the subject who had Bladder carcinoma were 88.2% in male and 11.8% were female.

Among the subject who had renal carcinoma 50% were in male and 50% were female.

Among the subject who had ureter carcinoma and trauma all were female ice 100% female.

Among the subject who had calculi 63.6% were in male and 36.4% were female.

Among the subject who had infection 66.7% were in male and 33.3% were female

P value 0.018, there was a significant difference found between sex and cause of haematuria

55

Graph 16: - Graph showing Distribution of subjects according sex and cause of

haematuria

56

DISCUSSION

Haematuria is a common clinical problem, has a prevalence rate of 9-18% and can originate

from any site along the urinary tract2.MDCTU is firmly established as the most sensitive

modality for determining the cause of haematuria. It is the gold standard in detection of renal

parenchymal masses, urothelial tumors, and extrinsic lesions18

.Hence many authors consider

it as a potential one stop investigation for the spectrum of urinary tract disorder presenting

with haematuria2.

In our study, out of the 45 patients who underwent CT Urography, all were found to have

positive findings .Hence MDCT urography had highest percentage of identifying pathological

findings (Sensitivity 100%) among the patients with haematuria. Of the patients examined

there were 30(66.7%) male and 15(33.3%) female patients with male: female ratio 3:1. Age

distribution in our series ranged from 19 to 74 years. Maximum numbers of patients were in

the age group of 40-49 years (29%). Most common age group for neoplasms were >40years,

trauma and infection were the most common cause of hematuria in young patients(20-

29years) of age group.

Most of the patients presented with macrohematuria, all those who presented with

microhematuria had infection as the cause.

Most common cause of haematuria was carcinoma of bladder(37.8%) ,second most common

cause being urolithiasis(24.4%) followed by renal cell carcinoma(17.8%),trauma(8.9%) and

renal infection ( 6.7%) and ureteric carcinoma(4.4%).

In the study conducted by Cowan NC et al 21

, bladder urothelial carcinoma was the most

common cause of haematuria detected on MDCT (18.6%), followed by calculi (16.3%). In

their study, Maheshwari E et al 32

also reported bladder carcinoma (9%) and calculi as the

leading causes of haematuria on MDCT.

62

In the present study, urinary bladder was the most commonly involved organ. The findings of the

present study are comparable to those obtained by Cowan NC et al 21

and Maheshwari E et al 48

,

where urinary bladder was the most commonly involved primary organ with 19.8% and 11%,

respectively. CT was 100% sensitive in detecting bladder neoplasm in our study. Out of the total

17 patients of bladder neoplasms causing hematuria, there was a definite male preponderance;

similar distribution was reported in a study done by Tyagi et la18

. In our study bladder TCC was

the most common histopathological type of malignancy.

All cases of TCC i.e.17(100%) were seen as enhancing mass lesion and majority of the cases

showed papillary mass protruding into lumen in 11/17(64.7%) cases. In addition, calcification in

11.7%, VUJ involvement was noted in 47%, local infiltration in 35.29%.

All RCC showed intense heterogenous post contrast enhancement, Necrosis was found in 4

patients (50%), calcification in 2(25%) patients. Extension through renal vein was seen in

3(37.5%) patients

respectively. Out of 8 cases of histopathologically proven RCC, 4 patients had distant metastasis.

Similar findings are seen in other studies like Tyagi et la 18

and Kim et al 49

.

63

CONCLUSION

Multidetector CT urography with its multiplanar capabilities detects with high accuracy the

entire spectrum of urinary tract pathologies responsible for haematuria.

Most common etiology of haematuria in our setting was urinary bladder carcinoma as

established by MDCT urography with 100% sensitivity.

MDCTU can be considered as the first line imaging modality for detection of neoplastic masses

with high sensitivity, useful for both tumor detection and extraurinary staging in urothelial

carcinoma.

64

SUMMARY

The aim of the present study is to evaluate the role of MDCT in patients with hematuria and to

study the MDCT features of various common etiologies causing it. Also highlighting the use of

MDCT urography over other modalities in detection of hematuria.

In our study out of the 45 patients referred for CT Urography in our hospital, all were found to

have positive findings on Multi-detector CT(MDCT). Most common cause of haematuria was

carcinoma of bladder(37.8%), second most common cause being calculus(24.4%),followed by

renal cell carcinoma(17.8%),trauma(8.9%),infection( 6.7%) and ureteric carcinoma(4.4%).

MDCTU by using its multiplanar and 3D capabilities is highly accurate and specific in detecting

the causes of hematuria. It can show the exact site of involvement in very high percent of cases.

In addition to hematuria, MDCT can find out various associated and incidental findings which

may not be suspected clinically.

65

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70

ANNEXURES

INFORMED CONSENT FORM

Study topic: “Role of multidetector CT urography in evaluation of causes of haematuria”

You will be subjected to MDCT urography study of abdomen and pelvis. You will be followed

up for the final diagnosis with histopathological findings or findings at the urological procedure.

At any point of time during the study if u wish to withdraw yourself you may do so as there is no

binding on you.

This is for your information that you will not derive any monetary benefit from this study and the

outcome of this study will be purely for the benefit of the institution.

I, Mr. / Mrs. __________________ aged ____ years would hereby declare that I have been

explained in the language best understood by me / us, by Dr. Maithri S Patel regarding proposed

study and give my consent to include myself as a subject in the dissertation “Role of

multidetector CT urography in evaluation of causes of haematuria”. The risks involved have

been explained in detail.

I have voluntarily given this informed consent for publication of data and I will not make any

claims whatsoever, against any individual or the institution in the process of research program, in

case of any untoward happens in the process.

SIGNATURE OF THE DOCTOR

SIGNATURE OF THE PARENT/GUARDIAN

Name of the Doctor: Name:

Date: Relation:

71

CASE SHEET PROFORMA.

PATIENT’S DEMOGRAPHIC DATA.

1.Name-

2.Age-

3.Sex-

4.Address-

5.O.P/I.P.Number-

6.Date of admission-

Any other co-morbidities

CLINICAL HISTORY-

History of visible hematuria any associated symptoms like dysuria, reduced flow of urine and

loss of appetite.

CT scan findings:

1.Calculus

Renal/Ureteric/Vesical

2.Infection

Acute/chronic pyelonephritis

3.Neoplasm

a) Renal cell carcinoma-

CT features-enhancement/necrosis/hemorrhage/calcification/hydronephrosis/renal vein or IVC

invasion/distant metastasis.

b) Urinary bladder carcinoma-CT features –enhancement/growth

pattern(papillary/sessile)/calcification/VUJinvasion/hydroureteronephrosis/focal wall thickening

/local infiltration/metastasis.

72

c)Ureteric carcinoma.

4.Trauma-

Renal/bladder injury

Follow up of the patients for final diagnosis with histopathological diagnosis or

urological procedure performed if any.

73

Sl. Age(years) Sex

Clinic al symp t o m s

Diagnosis

No.

hematuria reduced Dysuria Loss of Calcu lu s Infection Neoplasm Traum a

flow appetitte

macro micr o renal ureter vesical Acute pyelonephritis Chronic renal tumor Urinar bladder Ca Ureter CA

stagh

orn

nono

bstr

ucti

ve

obstr

uctiv

e

uppe

r

mid

dista

l

dista

l ob

struc

tion

perin

ephr

ic

fats

trand

ing/

colle

ction

asso

.cys

titi

s

rena

l atr

ophy

corti

cal

scarr

ing

enha

ncem

ent

necro

sis

hem

orrh

age

calc

ific

atio

n

hydr

onep

hros

is

lym

phad

enop

athy

rena

l vei

n in

vasi

on

IVC

inva

sion

dista

nt

met

asta

sis

enha

ncem

ent

grow

th

patte

rn

calc

ific

atio

n

VUJ

inva

sion

hydr

oure

tero

neph

rosi

s foca

l wal

lthic

keni

ng

loca

l in

fitra

tion

met

asta

sis

papil la r y sessile

1 29 M presen t present present

2 45 F presen t present present present present

3 33 M present present present present presen t

4 55 M presen t presen t present present present present present presen t

5 58 M presen t presen t mid ureter TCC

6 58 F presen t presen t present

7 47 M presen t presen t present

8 48 F presen t present

9 49 F presen t presen t present

10 55 M presen t presen t present present present presen t

11 19 M presen t presen t prese nt ( b la d d er ruptu re )

12 25 M presen t prese n t( r e n a l injur y)

13 65 M presen t present *present

14 56 M presen t presen t presen t present presen t present

15 66 M presen t present presen t present presen t present present *urethral

16 60 F presen t presen t present

17 55 F presen t present

18 25 M presen t present

19 28 F present present present

20 25 M present present presen t present

21 60 M presen t present presen t

22 47 F presen t present

23 43 F present presen t

24 49 M presen t presen t present present presen t present

25 47 M presen t presen t present present presen t present

26 35 F presen t present presen t

27 61 M presen t presen t presen t present

28 75 M presen t presen t presen t

29 70 F presen t presen t present

30 22 M presen t present present present presen t present prese n t( l iv e r and lung)

31 65 F presen t present present presen lung

32 58 M presen t present present presen t present present (lung)

33 64 M presen t present present

34 25 M presen t presen t present

35 48 M presen t presen t present

36 23 M present prese n t( g ra d e III)

37 70 M presen t distal ureter

38 49 F present present present present

39 58 M presen t present

40 54 M presen t present

41 50 M presen t presen t present present presen t

42 54 M presen t presen t presen t present presen t present

43 40 M presen t presen t present present

44 46 F presen t present presen t

45 48 F presen t present present presen t present present liver

a. b.

FIGURE 5(a &b). Axial images of contrast enhanced CT scan of upper abdomen shows

large expansile infiltrative heterogeneously enhancing mass lesion in the left kidney

infiltrating the left renal vein(5a) with contiguous spread to left adrenals(5b).

FIGURE 6. Coronal images of the abdomen show multiple dilated and tortuous

pampiniform plexus of vein in the left scrotum-s/o varicocele.

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FIGURE 7a & b(a-nephrogenic phase and b-urographic phases). Axial images of the

pelvis showing well defined enhancing papillary growth in the posterior and left lateral

wall of urinary bladder involving the left vesico-ureteric junction and distal left ureter.

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a. b.

FIGURE 8 a &b (Axial and coronal images). Well defined enhancing soft tissue

attenuating lesion within the lumen of the right ureter at the level of L5 to S1 vertebra.

Figure 9. Coronal image of the abdomen in corticomedullary phase showing a wedge-

shaped hypoattenuating hypo enhancing area in the mid and lower lower pole of the

right kidney involving the cortex and the medulla and part of calyces.

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FIGURE 10. Sagittal image in corticomedullary phase showing an extracapsular

hematoma contained within the gerota’s fascia along the mid and lower pole of the right

kidney seen communicating with the intraparenchymal hematoma.

Figure 11. Axial image at the level of the kidneys of the same subject as in fig 10 and 11

shows no extension of the intraparenchymal hematoma into the renal pelvis and normal

renal hilar vessels.

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Figure 12. Axial image in urographic phase of the same subject in Fig 10 & 11 shows

normal excretion of contrast into the renal pelvis with minimal narrowing of the proximal

ureter.

Figure 13.MDCT MPR coronal image of the abdomen in unenhanced phase shows

staghorn calculus in the left kidney.

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