CT KUB

Dr. Deepak David

1st year Urology Resident
 Noninvasive imaging method employing
tomography where digital geometry processing is
used to generate a 3D image of the internal of the
body from a large source of 2D x-ray images taken
around a single axis of rotation.

Computed The word tomography originating from greek words

Tomograph TOMOS meaning slice  and GRAPHY meaning to
write.
y
Produces a volume of data  processed through a
process known as WINDOWING, in order to
demonstrate various internal structures of body
based on their ability to block the x-ray image.
 Individual slice data is generated using an X-
ray source that rotates around the patient ,
X-ray sensors are positioned on the opposite
side of the circle from the X-ray source.

Many data scans are progressively taken as

Basics the body is gradually passed through the
gantry. The images are combined together
by reconstruction.

Contrast within soft tissues can be increased

by injection of iodine-based solutions.
HISTORY

• The first commercially

available CT scanner was
invented by Godfrey
Newbold Housnsfield in
England using x-rays in
1972.
• McLeod Cormak of tufts
university, USA
independently invented a
similar process and they
shared a nobel prize in
medicine in 1979
Breakthroughs

Helical CT 16 slice CT

1980s 1990s 2002 2005

Multislice CT 64 slice CT
Helical Scanning
 Computer constructs a graphic image, assigning a
number(called Hounsfield unit after Geoffery Hounsfield)
to represent the radiodensity at each point.

HOUNSFIEL Calibrated with reference to water

D UNIT
(HU) Radiodensity of distilled water at STP is defined as zero
SCALE Hounsfield units (HU),

Radiodensity of air at STP is defined as -1000 HU

ROLE OF CT SCAN IN DIAGNOSIS OF
UROLOGICAL DISEASES
• Heterotopic  position/congenital anomaly  of kidney
like pelvic , thoracic kidney, horse shoe kidney 
• Complicated UTI like EPN,XGP
• Renal /Perinephric abscess
• Renal cystic diseases
• Stone diseases
• Obstructive uropathy
• Renal tumors
• Renal trauma
• Renal artery stenosis
CT Urogram
 Diagnostic examination optimized
for imaging the kidneys, ureters and
bladder.
CTU Working Group, 2008

Definition
The examination involves the use of
multi-detector CT with thin-slice
imaging, intravenous  administration
of a contrast medium, and imaging
in the excretory phase
Best single diagnostic evaluation for most uropathology except infection.

In addition to optimal opacification, distension appears to be an important

factor for thorough evaluation of renal collecting system and ureter.

For this, IV saline is given at the same time as the contrast material to aid in
the detection of subtle filling defect and discrimination between urothelial
neoplasm and other filling defect.
 • Requires use of intravenous injection  of  

• Ionic (diatrizoate /metrizoate

/iothalmate)
Contrast
Media • Nonionic iodine based contrast
material (Iohexol /Iodixanol/Iov
ersol/Iopamidol/Iopromide) 
 • Detect parenchymal masses in
the kidney with a sensitivity of
CT 94%, compared to 67% for
urography In plain film excretory urography
heamaturia and 79% for ultrasound
• Various studies showing
sensitivity of CTU between
82-100% and specificity
between 83-99%
Cowan, N. C. Nat. Rev. Urol. 9, 218–226 (2012); published online 13 March
2012; doi:10.1038/nrurol.2012.32
Cowan, N. C. Nat. Rev. Urol. 9, 218–226 (2012); published online 13 March 2012;
doi:10.1038/nrurol.2012.32
PROCEDURE
 Supine positioning is standard
practice for CTU.
Patient
positioning
Prone imaging may be
advantageous in the unenhanced
phase to discriminate uretero-
vesical junction stones from stones
passed into the bladder
Contrast Injection

Inject standardized volumes (e.g. 125– 150 ml of 300 mgI/ml CM)

at set injection rates (2–3 ml/s) in all adult patients.

A single bolus of CM, combined with a three- to four-phase study

using unenhanced, nephrographic and excretory phase series,

A split-bolus CM injection, combined with a two to three-phase

study
 Single-bolus CM injections use 100–150 ml of
non-ionic CM (300–370 mgI/ml) injected at a
rate of 2–3 ml/s 

Single If a corticomedullary phase is employed, data

Bolus acquisition is usually started 25–35 s after start
of CM injection. 
Protocol
The nephrographic phase starts after a delay of
90–110 s after start of the CM injection while for
the final excretory phase a fixed delay of 240–
480 s after the start of CM injection has been
used. 
 Either a smaller first injection of
30–50 ml at a rate of 2 ml/s,
followed 2–15 min later by a
larger second injection of 80–100
ml at 2–2.5 ml/s is used OR
Double
bolus a larger first injection of 75–100
ml injection at a rate of 2– 3 ml/s,
followed 3–10 min later by a
smaller second injection of 45–50
ml at a rate of 2–3 ml/s
 A small first bolus (30 ml at 2 ml/s) is used for
opacification of the excretory system,
followed 7 min later by a small second bolus
(50 ml at 1.5 ml/s) for the renal parenchyma
and veins, and finally followed 20 s later by a
larger third bolus (65 ml at 3 ml/s) for arterial
information
Triple Bolus
One combined corticomedullary-
nephrographic-excretory phase data
acquisition is obtained some 510 s after start
of the first bolus
 Renal parenchymal
calcifications.
Unenhance
For pre contrast
d CT
attenuation measurement.
images
Excluding hemorrhagic
changes.
Enhanced Arterial phase
images
Corticomedullary
phase
CT scan • 25 seconds • 30 to 70 sec
• Vascular anatomy • Characterize renal
• Vascular masses better
abnormalities – AV • Invasion of renal
malformations vein best depicted
during this phase.
Enhanced Nephrographic phase
images
Delayed images
• 3 to 5 minutes.
CT scan • 90 to 180 seconds • Contrast is excreted
• Renal parenchyma for into the collecting
neoplasms, scarring, system
and inflammatory • Evaluating central
disease. renal masses and
• Renal veins can be urothelial
evaluated for possible abnormalities.
tumor invasion. • The bladder is seen
best in 20-minutes.
CT CONTRAST  NORMAL
NEPHROGENIC PROGRESSION
• At the level of renal hilum 
• CT attenuation values of
kidneys slightly less than
that of liver and pancreas
Cortical medullary phase

•Enhanced CT during cortical

nephrogenic phase
•20 to 80 sec after injection of
contrast
•Increased enhancement
of renal cortex compared
to medulla
•Renal veins are less opacified
compared to aorta and renal arteries
Nephrogenic phase

• Homogenic nephrogenic phase

80 to 120 sec after injection of contrast.

• Homogenous,uniform ,
increased attenuation of
contrast in renal
parenchyma
• Renal pelvis is paper thin and not
visible on ct scan
Excretory phase

• Excretory phase
• 3 mins after
injection of
contrast 
• Contrast
medium in renal
pelvis bilaterally
Urolithiasis
Stone Protocol
• For detection of renal, ureteral, or bladder stones

• Non-contrast CT imaging from kidney to bladder.

• Follow-up imaging with non-contrast plain film radiography

USES OF CT IN STONE

To make accurate diagnosis

To assess- stone burden,composition& fragility

To plan appropriate treatment strategies

Valuable tool in follow up.

 • Supplement axial scans in
• Tracing entire length of ureter
CORONAL • Identify exact site of stone impaction
• Detect small stones <2mm
REFORMED • Differentiates calcifications from
IMAGES • Phleboliths
• Calcified vascular plaques
• Renal parenchymal calcifications
 • DIRECT SIGNS
• Stone within ureteral lumen with proximal
dilatation and normal distal caliber
CT SIGNS • OTHER SIGNS
• Hydroureter, Hydronephrosis
• Perinephric stranding
• Periureteral edema
 • Phleboliths are focal calcified venous thrombi

Stone
• Frequently seen along the normal anatomical
imitators course of the lower ureter. 
SOFT-TISSUE
RIM SIGN
• Caused by edema of ureteral wall
surrounding a stone at site of
impaction

• Distinguish a stone in the ureter

from a phlebolith in an adjacent
vein
COMET SIGN

•Aid in the differentiation of a phlebolith from

a stone in the ureter, especially in the
anatomic pelvis
•Calcified phlebolith represents the comet
nucleus and the adjacent, tapering,
noncalcified portion of the vein is the comet
tail.
•Reliability of the comet sign is not as great as
that for the soft-tissue rim sign, however.
URETERAL CALCULI PHLEBOLITH

• SOFT TISSUE RIM SIGN • COMET TAIL SIGN

• Larger stones - • Rim sign absent 
stretching of ureteral
wall, the "rim" sign • Seen in true pelvis often
not seen below the distal ureter

• Opacified centre • Central lucent area

 Measure stone size

Most accurate way is to measure with

bone window setting with magnification
Stone
burden Useful in deciding treatment

Stone burden of more than 700 c.mm is

a significant predictor of failure for SWL
 Best seen with bone window setting and high
resolution with thin sections

Either heterogenous / homogenous

Stone Heterogenous stones – have internal low

fragility attenuation areas (voids / dark areas)
• Render susceptible to SWL

Homogenous stones–uniform internal structure

• Harder to break
 (almost)
(almost) all
all stones
stones
Computed Tomography dense
dense on
on CT
CT

Source Undetermined
Computed Tomography

Source Undetermined

Secondary
Secondary signs
signs of
of ureteral
ureteral obstruction
obstruction
 Computed Tomography

Source Undetermined
Huge
Huge bilateral
bilateral renal
renal calculi
calculi
 Almost all ureteral and renal stones, including
those containing uric acid, can be detected by
non-contrast CT imaging except some indinavir
stones.
Urolithiasis The accuracy in diagnosing urolithiasis in
and patients with acute flank pain has been
Nephrolithi determined to be as high as 97%, sensitivity of
96%-100 % and specificity of 92%-100%.
asis
Using low dose CT protocols,the specificity and
sensitivity of unenhanced low dose helical CT
scan is approx.96% and 97% respectively.
RIM SIGN

•Seen with chronic hydronephrosis

•Enhancement occurs in residual,
but markedly atrophic, renal
parenchyma, surrounding the
dilated calices & renal pelvis.
•Inner margin of hydronephrotic
rim is concave towards renal hilum,
and enhancement of cortical
columns between the dilated
collecting system elements may be
seen.
  HIV • Intravenous contrast. 
positive • These calculi are typically non-radio opaque
patients  & • may go undetected on stone protocol CT scans. 

Indinavir •  use of 3-D reconstruction techniques of

contrast-enhanced pyelographic phase images
stones
 • Radiation dose is high (about 500 mrem) 

Disadvanta • For plain film excretory urography (about 150-

350 mrem)
ge of
"stone • Non-contrast plain film radiography (about 13
mrem)
protocol"
CT • Better to avoid CT for follow up studies 

• Use non-contrast plain film radiography instead.

M. A. Bosniak

Renal Cysts
 Usually simple benign cysts

Haemorrhage
Complicated Infection

RENAL
Ischemia

CYSTS When this occurs - difficult to differentiate

these complicated cysts from cystic renal cell
carcinomas (10% of all renal cell carcinomas)

Imaging is a reliable means for differentiating

benign from malignant cystic lesions.
 Calcification
SIMPLE Hyperdense / high signal
CYSTS & Not Septations
So SIMPLE Multiple locules
CYSTS Enhancement
Nodularity / wall
thickening
Bosniak I renal cyst

• Simple cyst with a hairline thin wall

• No septa
• No calcifications
• No solid components
• It measures water density in
Hounsfield
• Does not enhance with intravenous
administration of contrast agent
Bosniak II renal cyst

•  Cyst
may contain a few hairline thin
septa and fine calcifications or a short
segment of slightly thickened calcification
may be present in the wall or septa

• Do not enhance with intravenous

administration of  contrast agent

• Uniformly high-attenuation lesions <3 cm

(so-called high-density cysts) are well
marginated
Bosniak IIF renal
cyst

•  Cysts may contain multiple hairline thin

septa or minimal smooth thickening of their
wall or septa
•  Their wall or septa may contain calcifications
that may be thick and nodular, but not
measurable
•  Observed but not measurable enhancement
•  These lesions are generally well marginated
•  Totally intrarenal nonenhancing high-
attenuation renal lesions ≥3 cm are also
included in this category
 • “Indeterminate” cystic masses have thickened irregular or
Bosniak III renal smooth walls or septa

cyst • Measurable contrast enhancement is

present
Bosniak IV renal • Clearly malignant cystic masses can have all the criteria of category III

cyst But also contain enhancing soft

•  

tissue components.
Renal Masses
RENAL MASS PROTOCOL
• For characterization of renal masses detected by other imaging
studies, e.g. ultrasound, MRI

• Non-contrast followed by contrast CT imaging of kidneys only

 Most Renal Cell Carcinomas are
now diagnosed in presence of vague
signs & symptoms
CT SCAN IN Most are <3 cm in diameter
This lead to improved survival and
RENAL segmental resection
MASSES CT has overall accuracy of 95% in
diagnosis
CECT useful in distinguishing STAGE I
& II from STAGE III & IV
CT SCAN IN RENAL MASSES

Simple Cyst Benign

Indeterminate
Cyst ?

Solid Mass Malignant

CT SCAN IN RENAL
MASSES
Computed Tomography
• Current gold standard
• Non-contrast scan, then scan with intravenous
contrast
• Enhancement = Hounsfield units (density)
increase by > 15 with contrast
• 3 to 5 mm maximum cut width
• Spiral CT - single breath hold
• Minimize motion artifact
• Exact duplication of cuts
 CT SCAN IN RENAL MASSES

 Any renal mass that enhances by more than 15 Hounsfield units (HU) should be
considered a renal cell carcinoma (RCC) until proved otherwise.

 Solid masses that also have substantial areas of negative CT attenuation

numbers (below -20 HU) indicative of fat are diagnostic of AMLs

Hartman et al, 2004 , Nelson and Sanda, 2002

• Un-enhanced CT showing solid , right posterior renal mass

• On administration of contrast , mass enhances to more than

20 HU

• Highly suggestive of RCC

LARGE BILATERAL RENAL
ANGIOMYOLIPOMA
Angiomyolipoma With
Parenchymal Indendation
Perinephric Fat
Invasion

•CT showing right renal tumor

with perinephric stranding
suggestive of  invasion of peri
nephric fat
 Ct Scan In Renal Masses

• Approximately 10% to 20% of small, solid, CT-enhancing renal masses with

features suggestive of RCC prove to be benign after surgical excision

CT IN RCC
•Diagnosis,staging and follow up of patients.
•Most frequently used staging technique,with accuracy ranging
between 72 and 90%.
•Accuracy for lymph node staging is 83 and 89%.
•MRI is not significantly better than CT at detecting lymph node
disease
•Sensitivity for detection of renal venous tumor thrombus and
inferior venacaval involvement are 78% and 96%, respectively
SIGNS ON CT
•Renal capsular invasion is difficult to diagnose unless the tumor

obviously extends into the perinephric space. Recognized by

•An indistinct tumor margin.

•Blurring of the renal outline.

•Thickening of the perirenal fascia.

•Strands of soft tissue spreading into the perinephric fat resulting in

‘webs’ or ‘wispy’ densities.

• False-positive diagnoses occur and in up to 50% of patients with Stage I (T1-T2)
disease, there is perirenal stranding and fascial thickening without perinephric
tumor spread caused by:
• Perinephric edema.

• Fat necrosis.

• Fibrosis from previous inflammation, stone disease, etc.

RCC -Signs of venous involvement

• Venous enlargement

• Abrupt change in the caliber of the vein

• Intraluminal areas of decreased density or filling defects.

• Demonstration of collateral vessels

  CT & IVC THROMBUS
• Most important sign of venous tumor invasion is a
persistent filling defect within the renal vein or IVC
following IV contrast administration.
• No false-positive results for this sign.
• Ipsilateral renal vein enlargement on CT without
identifiable tumor thrombus is not a reliable sign of
venous tumor extension.
• Sign is associated with 65% false-positive rate and 90%
false-negative rate for diagnosing tumor, partly because
• 78% of RCCs are hypervascular, causing increased flow with
enlargement of the renal vein. Conversely, tumor thrombus does
not necessarily cause enlargement of the veins.
Level of venous involvement
Blute et al (2004)-
• 0- Thrombus limited to renal vein, detected clinically or in HP of the
specimen
• 1- Thrombus extending </ = 2 cm above renal vein
• 2- Thrombus extending >2 cm above renal vein but below hepatic
veins
• 3- Thrombus at or above level of hepatic veins but below diaphragm
• 4- Thrombus extending above diaphragm
 Abdominal CT showing Rt. RCC (white
arrow) with a large tumor thrombus
extending into the IVC (black arrow).

B: Abdominal CT for the same

patient’s Rt. kidney (Upper pole) with
a large tumor thrombus extending
more cephalad in the IVC (black
arrow).

C: Venacavography (for the same

patient) showing dilated IVC
collaterals due to a large tumor
thrombus extending into the IVC
(white arrows) up to right atrium
(black arrows).
 STAGE I confined to kidney

STAGE  2 limited to Gerotas 

A involves main renal vein

ROBSONS
STAGE 3A

CLASSIFICATI STAGE 3B B involve regional LNs

ON SYSTEM STAGE 3C
C involve both renal vein &
LNs
STAGE 4A A adjacent organ involved

STAGE 4B B distant mets

 Presence of calcification
Small size at
signs of good presentation
prognosis Degree of necrosis

Vascularity of tumour
CONVENTIONAL CLEAR CELL RCC PAPILLARY RCC
CT scans of TNM stage T1a tumor in CT scans of TNM stage T1a tumor in
corticomedullary and nephrogenic phases corticomedullary and nephrogenic phases
show typical hypervascularity of show typical hypovascularity of tumor
tumor(Arrow, A) and subsequent washout (arrow)
(arrow, B).
CHROMOPHOBE RCC
CT scans of TNM stage T2 tumor in
corticomedullary and nephrogenic
phases show hypovascularity of tumor
(arrow)

Medullary RCC (large arrow) and adjacent

paraaortic adenopathy (small arrows) in
36-year-old man.
CT shows TNM stage T1b N1 tumor
Solid, Enhancing Renal Mass on CT is RCC until Proven
Otherwise
• Other possibilities
• Oncocytoma
• Benign, but indistinguishable from RCC on
imaging
• Central fibrous stellate scar
• Hemorrhage and necrosis rare
• Angiomyolipoma
• Benign, but can bleed if large
• Usually diagnosed by imaging fat
• Differ by attenuation value
• Inflammatory mass
• History of febrile illness
• Lymphoma
• Malignant, but no surgery
Source Undetermined

Oncocytoma ?
RENAL ANGIOMYOLIPOMA

• When negative attenuation values of less than 20 HU are

recorded in renal tumors, angiomyolipomas may be reliably

diagnosed in the appropriate clinical setting, and the diagnosis

of renal cell carcinoma can generally be ruled out

Angiomyolipomas

• Usually well-marginated,cortical heterogeneous tumors with predominant fatty

attenuation

• Higher attenuation seen in tumors with minimal fat content

• Average attenuation depends on the relative proportions of fat and other soft

tissue in the angiomyolipoma.

 Angiomyolipoma

Source Undetermined
Renal Trauma
 Provides valuable anatomic
and functional information

Provides the most definitive

CT IN RENAL staging information

TRAUMA Provides information on

associated injuries

Imaging modality of choice for

renal trauma
 Urinary • Suggests PUJ
extravasation
medial to avulsion or renal
kidney pelvic injury
Renal Trauma Hematoma
CT Findings – medial to
kidney,
• Suggests pedicle
Major Trauma displacing it
laterally
injury

Lack of
contrast • Suggests arterial
enhancement injury
of kidney
 AAST
Renal
trauma
grading
Grade 1 renal injury, contusion. CECT Grade 1 renal injury, subcapsular
scan shows ill-defined area of hematoma. CECT shows crescentic high-
hypoenhancement in the medial right density fluid collection around the left
kidney kidney. Note the well-defined outer
margin.
Grade 2 renal injury, subcapsular and
perinephric hematomas. CE shows an ill- Grade 2 renal injury, perinephric
defined fluid collection in the left perinephric hematoma. CECT shows an ill-defined
space. There is also a subcapsular hematoma fluid collection in the left perinephric
with deformity of the renal parenchyma space.
Grade 2 renal laceration. CE shows a Grade 2 renal laceration. Delayed image
superficial (less than 1 cm deep) renal shows no urinary contrast extravasation.
parenchymal defect with a large CECT shows a superficial (< 1 cm deep)
perinephric hematoma renal parenchymal defect with a large
Grade 3 renal laceration. CT scan of the
abdomen after intravenous contrast Grade 4 renal injury segmental infarction.
administration shows irregular Contrast-enhanced CT scan of the upper
nonenhancing renal parenchymal defect abdomen shows a segmental area of
with extension greater than 1 cm deep to nonenhancement in the upper medial left
near the renal pelvis. This delayed image kidney without associated renal
showed no urinary contrast extravasation laceration.
 Grade 5 renal injury. Shattered kidney. CECT
Grade 5 renal injury. Shattered left kidney.
shows transection of the right kidney with a
CECT shows several deep lacerations extending
large hematoma around and between the 2
into the collecting system of the left kidney
halves of the kidney. The 2 halves are both
with separation of the fragments.
perfused because there were 2 renal arteries.
Delayed images show urinary contrast
extravasation.
Contrast CT showing a shattered kidney (multiple
fractures).
 Introduction

CTU

Stone disease
Summary
Renal Cysts

Renal Masses

Renal Trauma