Computed Tomography Urogram Research Articles

Radiomics-Based Computed Tomography Urogram Approach for the Prediction of Survival and Recurrence in Upper Urinary Tract Urothelial Carcinoma.

Upper tract urothelial carcinoma (UTUC) is a rare and aggressive malignancy with a poor prognosis. The accurate prediction of survival and recurrence in UTUC is crucial for effective risk stratification and guiding therapeutic decisions. Models combining radiomics and clinicopathological data features derived from computed tomographic urograms (CTUs) can be a way to predict survival and recurrence in UTUC. Thus, preoperative CTUs and clinical data were analyzed from 106 UTUC patients who underwent radical nephroureterectomy. Radiomics features were extracted from segmented tumors, and the Least Absolute Shrinkage and Selection Operator (LASSO) method was used to select the most relevant features. Multivariable Cox models combining radiomics features and clinical factors were developed to predict the survival and recurrence. Harrell's concordance index (C-index) was applied to evaluate the performance and survival distribution analyses were assessed by a Kaplan-Meier analysis. The significant outcome predictors were identified by multivariable Cox models. The combined model achieved a superior predictive accuracy (C-index: 0.73) and higher recurrence prediction (C-index: 0.84). The Kaplan-Meier analysis showed significant differences in the survival (p < 0.0001) and recurrence (p < 0.002) probabilities for the combined datasets. The CTU-based radiomics models effectively predicted survival and recurrence in the UTUC patients, and enhanced the prognostic performance by combining radiomics features with clinical factors.

Chronic back pain in untreated gout

A 41-year-old man with a 10-year history of untreated chronic tophaceous gout presented with acute flare of gouty arthritis. He has chronic low back pain which has become more severe for the past 1 year. Clinically he has tenderness at lower lumbar spine although there was no neurological deficit. Laboratory test revealed raised inflammatory markers (ESR 70mm/hour) and C-reactive protein 287.1 mg/L, reactive thrombocytosis and leucocytosis, renal impairment and elevated serum uric acid (780 μmol/L). He had microscopic hematuria and ultrasound showed right mild hydronephrosis without any calculi identified. Computerized Tomography Urogram (CTU) confirmed the findings of an obstructive right hydronephrosis and hydroureter due to a right ureteric calculus. Incidentally, CTU revealed a lobulated, heterogenous hyperdense soft tissue ossified mass measuring (4.6x7.3x8.1 cm) at lumbar vertebral bodies (L2-L4) with overhanging edge erosions of adjacent vertebra mainly involving the facet joints, pedicles and lamina (Figure 1).

Urothelial Malignancy After Normal Hematuria Clinic Investigations: Does Non-visible Hematuria Need Reinvestigation?

Hematuria is the most common referral to Urology. Most initial evaluations are normal; however there are few medium- to long-term studies about these patients after they are discharged. This study was a retrospective observational case-control study. Patients with normal initial investigations in our hematuria clinic (HC) over a 2-year period in 2012-2013 were included. We reviewed the electronic records of patients choosing January 1, 2021, as our reference date providing a median follow-up of 99 months. The primary aim of this study was to assess the missed urothelial malignancy (UM) rate in this cohort and also the UM rate in those re-referred to the HC. The study included 573 patients of whom 24.6% (141/573) were re-referred to urology during the study period. The overall missed UM cancer rate was 0.5% and 0.2% died as a result in this follow-up period. The UM cancer rate in those re-referred was 4.3% and of those re-referred with visible hematuria (VH) the UM cancer rate was 5.7%. No patients re-referred with non-visible VH (NVH) were diagnosed with UM. The only urological death during this time was due to UM. All urological malignancy and mortality remain very low even at mediumto long-term follow-up after an initial normal HC investigation. In this study, no patients with recurrent NVH developed UM; therefore, recurrent NVH is unlikely to need reinvestigation. The risk of UM in those re-referred with VH is low but more substantial and warrants reinvestigation, which should include computed tomography urogram imaging.

Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use.

Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use.

The role of point-of-care ultrasound in the assessment of pelvic urine leakage and diagnosis of urinoma

BackgroundUrinoma, a rare condition resulting from urine leakage due to trauma to the kidney, bladder, or urethra, is typically diagnosed using enhanced computed tomography urogram with delayed imaging. This report presents two cases of urinoma likely caused by overdistention of the renal pelvis following excessive fluid intake and the presence of a ureteral stone.Case presentationWe present two cases of 36-year-old and 38-year-old patients who presented with flank pain. point-of-care ultrasound (POCUS) played a pivotal role in identifying perinephric fluid in Morrison’s space and the splenorenal space, respectively. These ultrasound findings guided further investigations, leading to definitive diagnoses via abdominal pelvic CT scans. Treatment involved prophylactic antibiotics and the successful placement of a double J stent into the renal pelvis over the wire under fluoroscopic guidance, which resulted in significant clinical improvement for both patients.ConclusionsThis study demonstrates the rare occurrence of urinoma from urolithiasis, the use of POCUS in expediting diagnosis and treatment, and the importance of interpreting sonographic images in the correct clinical setting.

RARE PRIMARY CLEAR CELL CARCINOMA OF BLADDER OF MULLERIAN ORIGIN: MORPHO- IMMUNOHISTOCHEMICAL PROFILING

Abstract Introduction/Objective Primary clear cell carcinoma of urinary bladder (PCCCUB) is a rare and aggressive cancer variant with uncertain and debatable histogenesis. The hypotheses include origins from the urothelium, pre-existing Müllerian precursors, or mesonephric remnants. Definitive diagnosis is achieved through histology and immunohistochemistry (IHC). We present an unusual case of PCCCUB in a sexagenarian woman. Methods/Case Report Patient with history of diabetes, hypertension, and smoking presented with gross hematuria. Computed tomography urogram revealed a 2.3 x 1.2 cm enhancing mass at the base of the urinary bladder. Patient underwent transurethral resection of the bladder tumor (TURBT). Histopathology revealed features of tubulo-papillary, solid, glandular structures with hyalinized stroma. Cytologic features varied from flat, hobnail, to polygonal with abundant clear to eosinophilic cytoplasm and prominent nucleoli. Immunohistochemistry revealed strong reactivity for PAX8, CK7, ER, and racemase; focal reactivity for vimentin, napsin A, p53, CA125; and non-reactivity for PAX2, WT1, PR, GATA3, pCEA, CK20, p63, p40, CD10, RCC, BRST-2, and mammaglobin. P53 showed a wild type staining pattern and Ki-67 was 10%. Combined morphologic and IHC features confirmed PCCCUB, and in the absence of muscularis mucosal invasion, tumor was staged pT1N0. PAX8 positivity and urothelial marker negativity excluded clear cell pattern of urothelial carcinoma. IHC also excluded nephrogenic adenoma, and metastasis. The female gender, and CK 7 (+)/CK 20 (−) profile supported Müllerian origin. Restaging TURBT showed consistent results. Subsequently, anterior pelvic exenteration and bilateral pelvic lymph nodes dissection was performed revealing muscularis propria invasion upstaging to mpT2 N0. Results (if a Case Study enter NA) NA Conclusion Poor prognosis, aggressive behavior, and advanced stage at the time of diagnosis warrants accurate diagnose of PCCCUB. Ambiguous origin, limited literature, and lack of clear management guidelines merit reporting in order to enhance knowledge of this rare and intriguing entity.

Evaluating the perceptions of Canadian urology residents and program directors regarding the current training in genitourinary imaging.

Competency in interpreting genitourinary (GU) imaging is an important skill for urologists; however, no nationally accredited GU imaging curriculum exists for Canadian urology residency training programs. The main objectives of our study were to 1) characterize GU imaging training in Canada; (2) evaluate residents' self-perceived competencies in interpreting GU imaging; (3) explore program directors' (PD) and residents' perceptions regarding the current imaging curriculum and suggestions for future directions. From November to December 2022, a survey examining current imaging education in residency, perceived resident imaging knowledge, avenues for improvement in imaging education, and the role of point-of-care ultrasound within urology was distributed to all Canadian urology PDs and residents. All PDs (13/13) and 40% (72/178) of residents completed the survey. Only two programs had a formal GU imaging curriculum. PDs and residents reported trainees were least comfortable interpreting Doppler ultrasound of renal, gonadal, and penile vessels. PDs reported that residents were most comfortable with non-contrast computed tomography (CT) scans (9.5/10), CT urogram (9.3/10), and retrograde pyelography (9.3/10). All but one PD favored increasing imaging training in their program. PDs highlighted the lack of time in the curriculum (n=3) and lack of educators (n=3) as the primary barriers to increasing imaging training in their program. Most PDs and residents believe there needs to be more imaging training offered at their institution; however, addressing this is challenging due to the limited time in the curriculum and the need for available educators.

Toward the Deimplementation of Computed Tomography Urogram for Patients With Low- to Intermediate-risk Microscopic Hematuria: A Mixed-method Study of Factors Influencing Continued Use.

Citing high costs, limited diagnostic benefit, and ionizing radiation-associated risk from CT urogram, in 2020 the AUA revised its guidelines from recommending CT urogram for all patients with microscopic hematuria to a deintensified risk-stratified approach, including the deimplementation of low-value CT urogram (ie, not recommending CT urogram for patients with low- to intermediate-risk microscopic hematuria). Adherence to revised guidelines and reasons for continued low-value CT urogram are unknown. With the overarching objective of improving guideline implementation, we used a mixed-method convergent explanatory design with electronic health record data for a retrospective cohort at a single academic tertiary medical center in the southeastern United States and semistructured interviews with urology and nonurology providers to describe determinants of low-value CT urogram following guideline revision. Of 391 patients with microscopic hematuria, 198 (51%) had a low-value CT urogram (136 [69%] pre-guideline revision, 62 [31%] postrevision). The odds of ordering a low-value CT urogram were lower after guideline revisions, but the change was not statistically significant (OR: 0.44, P = .08); odds were 1.89 higher (P = .06) among nonurology providers than urology providers, but the difference was not statistically significant. Provider interviews suggested low-value CT urogram related to nonurology providers' limited awareness of revised guidelines, the role of clinical judgment in microscopic hematuria evaluation, and professional and patient influences. Our findings suggest low-value CT urogram deimplementation may be improved with guidelines and implementation support directed at both urology and nonurology providers and algorithms to support guideline-concordant microscopic hematuria evaluation approaches. Future studies should test these strategies.

A case of life-threatening hematuria.

A 66-year-old male with a past medical history of hypertension and benign prostatic hypertrophy, not on anticoagulation, presented with difficulty voiding and hematuria. He was seen at an outside hospital earlier in the day and received a straight catheterization for urinary retention, he was prescribed antibiotics for a urinary infection, and he was discharged home. Subsequently, after discharge, he developed hematuria with inability to void, prompting a visit to our emergency department (ED). On arrival, the patient was uncomfortable appearing, tachycardic with a heart rate of 116 beats per minute and a blood pressure of 114/67 mm Hg. His lower abdomen was tender to palpation. A point-of-care ultrasound (POCUS) of the bladder was performed. The ultrasound demonstrated a distended-appearing bladder containing a large area of layering mixed echogenicity with intrinsic turbulent Doppler signal (Video 1). The patient had a three-way Foley catheter placed in the ED for continuous bladder irrigation. He had a computerized tomography (CT) angiography of the abdomen and pelvis that did not reveal any active hemorrhage. He also had a CT urogram. Initially, the hematuria improved, however, following the abnormal ultrasound Doppler images, the patient was admitted to the urology service. Although he was admitted, his hemoglobin declined from 12 to 7.9 g/dL, and he suffered a cardiac arrest. The reason for the arrest was presumed to be from hemorrhagic shock. There was return of spontaneous circulation after initiation of massive transfusion protocol. He underwent cystoscopy showing an enlarged median prostate lobe with active extravasation, requiring embolization of the prostatic artery by interventional radiology (IR). Hematuria and urinary obstruction are common causes of ED visits with multiple underlying etiologies.1 Emergency physicians are tasked with the challenge of determining which patients can be managed as outpatients. In this case, gross hematuria from an actively bleeding prostate led to the hemorrhagic shock requiring multiple transfusions and need for IR embolization. The most common etiologies of prostatic hematuria are benign prostatic hyperplasia, iatrogenic urologic trauma, prostate cancer, and radiation therapy.2 In this patient, POCUS showed turbulent Doppler flow within the bladder (Figure 1A), which was concerning for active bleeding, and ultimately led to the patient's admission and emergent urologic consultation. Additionally, the POCUS also showed layering mixed echogenicities seen within the distended bladder, indicating a clot at various stages (Figure 1B). This case illustrates the importance of considering POCUS in patients with urinary retention and hematuria, especially in the setting of recent catheter placement.

Utilization of Non-Transecting Pyeloplasty Techniques for Management of Recurrent Ureteropelvic Junction Obstruction

Introduction: Cases of recurrent ureteropelvic junction obstruction (UPJO) in patients who underwent a prior failed pyeloplasty may pose a difficult challenge for urologists. The increased findings of periureteral fibrosis and scarring in a reoperative field may increase the risk of ureteral devascularization and stricture recurrence. The goal of this study is to demonstrate three robotic non-transecting pyeloplasty techniques for patients in this setting. Methods: We conducted a retrospective review of our Collaborative of Reconstructive Robotic Ureteral Surgery (CORRUS) database for all consecutive patients between April 2012 and September 2019 who underwent a secondary pyeloplasty for management of a recurrent UPJO after prior failed pyeloplasty. Transecting (dismembered) and non-transecting pyeloplasty (YV plasty, buccal mucosa graft ureteroplasty onlay, or Heineke–Mikulicz) were the techniques used for secondary pyeloplasty. YV plasty was utilized in patients with high insertion UPJO without a redundant renal pelvis. A buccal mucosa graft ureteroplasty onlay was utilized for patients with nonobliterative long-segment UPJO and/or significant peri-ureteropelvic junction fibrosis. The Heineke–Mikulicz technique was utilized in patients with short-segment (≤1.5 cm) UPJO. Symptomatic absence of flank pain and radiographic obstruction (computed tomography urogram, renal scan, and/or renal ultrasound) were measures used to assess for postoperative success. Using a p < 0.05 for statistical significance, we used nonparametric independent sample median tests and chi-square tests to compare perioperative variables between transecting and non-transecting pyeloplasty. Results: Twenty-eight patients met the final inclusion criteria. Regarding preoperative variables, there was no difference in median operative time (p = 0.26) and estimated blood loss (p > 0.99) between both groups. In the non-transecting group, near-infrared fluorescence with indocyanine green was utilized more frequently (85.7% vs. 50.0%, p = 0.04). The non-transecting group also had a longer median stricture length (2.8 cm vs. 1.1 cm, p = 0.04). There was no difference in surgical success rates between both groups (85.7% for both groups, p > 0.99). Two patients who underwent a non-transecting buccal mucosa graft ureteroplasty onlay required postoperative management with percutaneous nephrostomy tubes caused by recurrent obstruction. Regarding postoperative variables, there was no difference in surgical success rates between both groups (p > 0.99). Conclusions: In patients with recurrent ureteropelvic junction obstruction after prior failed pyeloplasty, non-transecting pyeloplasty techniques, including YV plasty, buccal mucosa graft ureteroplasty onlay, and Heineke–Mikulicz pyeloplasty, are safe and feasible options. Given the potential technical challenges involved with secondary repair, non-transecting pyeloplasty techniques may offer benefits in reducing the risk of ureteral devascularization and preserving the fragile ureteral blood supply. J.J., M.L., J.K., and L.C.Z. have no conflicts of interest to disclose. M.D.S. is on the Scientific Advisory Board for Intuitive, a consultant for VTI Medical, and performs educational activities for Ethicon. D.D.E. is a paid speaker, consultant, and proctor for Intuitive Surgical, consultant for Johnson and Johnson, and founder/part owner of Melzi Corp. Authors have received and archived patient consent for video recording/publication in advance of video recording of procedure. The study was approved by the Institutional Review Board at Temple University (protocol number 20793). Runtime of video: 7 mins 15 secs This material was presented at the American Urological Association Conference in 2021 (https://doi.org/10.1097/JU.0000000000002052.04).

Hourglass appearance in cystocele with an impacted vesical calculus.

A 62-year-old hypertensive female presented with a mass protruding from the vagina for the past 20 years. She complained of dysuria and urinary incontinence for the past 3 months. There was no history of surgical intervention in the past. The examination revealed a tender irreducible total uterine prolapse (procidentia) and cystocele with a decubitus ulcer. Computed tomography urogram showed a total uterine prolapse along with the prolapse of a part of urinary bladder, with a vesical calculus of size 2.8 cm × 2.7 cm in the prolapsed part of the bladder, below the level of the pubic symphysis, with minimal wall thickening. After optimization, vesical lithotripsy and bilateral ureteric stenting were performed, followed by hysterectomy after 2 days.

Editorial Comment.

No AccessJournal of UrologyReview Article23 Mar 2023Editorial CommentThis article comments on the following:Diagnostic Imaging in the Evaluation of Asymptomatic Microhematuria: Systematic Review and Meta-analysis Elizabeth L. Koehne and John L. Gore Elizabeth L. KoehneElizabeth L. Koehne Department of Urology, University of Washington, Seattle, Washington More articles by this author and John L. GoreJohn L. Gore Department of Urology, University of Washington, Seattle, Washington More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003395.01AboutFull TextPDF ToolsAdd to favoritesDownload CitationsTrack Citations ShareFacebookLinked InTwitterEmail "Editorial Comment." The Journal of Urology, Publish Ahead of Print, pp. – REFERENCES 1. . Diagnostic imaging in the evaluation of asymptomatic microhematuria: systematic review and meta-analysis. J Urol.2023; 209(6):000-000. Google Scholar 2. . Can renal and bladder ultrasound Replace computerized tomography Urogram in patients investigated for microscopic hematuria?J Urol.2018; 200(5):973-980. Link, Google Scholar 3. . Stratifying risk of urinary tract malignant tumors in patients with asymptomatic microscopic hematuria. Mayo Clinic Proc.2013; 88(2):129-138. Crossref, Medline, Google Scholar 4. . Diagnostic and cost implications of the 2020 aua microhematuria guidelines: modeling impact in a large public health care system. J Urol.2022; 207(1):52-60. Link, Google Scholar © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetailsRelated articlesJournal of Urology8 Mar 2023Diagnostic Imaging in the Evaluation of Asymptomatic Microhematuria: Systematic Review and Meta-analysis Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Elizabeth L. Koehne Department of Urology, University of Washington, Seattle, Washington More articles by this author John L. Gore Department of Urology, University of Washington, Seattle, Washington More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-Assisted Laparoscopic Ureteroureterostomy of an Obstructive Retrocaval Ureter

Clinical History: A 32-year-old woman without significant medical history presented with incidentally found right severe hydronephrosis from a computed tomography scan after car accident. Her symptoms include only intermittent right flank pain. She has no dysuria or hematuria. Physical Examination: Examination was notable for right-sided costovertebral angle tenderness. Diagnosis: A computed tomography urogram scan was performed, which revealed severe right hydronephrosis with abrupt transition point at proximal ureter. The transition point was located posterior to the inferior vena cava, consistent with retrocaval ureter anatomy. Renal nucleotide scan showed 40% right kidney split function as well as a t1/2 of 35 minutes in right kidney, suggesting obstruction. Intervention: Given symptomatic pain, radiologic evidence of ureteral obstruction, good residual right renal function, and performance status, decision was made to perform a right robot-assisted laparoscopic ureteroureterostomy. Follow-up/Outcomes: Patient tolerated the procedure well and was discharged home the morning after surgery with drain removed. She had prompt return of daily activities and complete resolution of flank pain. Her ureteral stent was removed in clinic 6 weeks after the surgery. Repeat renal nucleotide scan 3 months after the surgery demonstrated resolution of obstruction with new t1/2 of 8.7 minutes. Patient Consent Statement: The author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. The authors have no conflicts of interest that may alter the results of this study. Runtime of video: 4 mins 28 secs

Laparoscopic Ureterolithotomy and Single-Use Digital Flexible Ureteroscope For Unilateral Large Ureteral Stone and Small Renal Stone.

BACKGROUND The removal of concurrent ureteral and renal stones within a single procedure has always been a challenge for urological surgeons. The incorporation of single-use digital flexible ureteroscopes into laparoscopic ureterolithotomy procedures has demonstrated effective removal of concurrent stones with a good clearance rate and decreased risk of bleeding and trauma. We report the successful removal of a unilateral upper ureteral stone and a smaller renal stone with this procedure. CASE REPORT A 60-year-old man visited the outpatient clinic with an ultrasonography report that revealed a large proximal ureteral stone with moderate hydronephrosis, accompanied by bilateral renal stones and prostatic hyperplasia. He had been experiencing urinary urgency for a year and was determined to undergo lithotomy. Due to his longstanding history of coronary artery disease and myocardial ischemia, the urologists decided that concurrent stone removal within an operation would be the best treatment. A preoperative computed tomography urogram measured the left ureteral and renal stones to be 2.0×0.8 cm and 0.6 cm, respectively. Both stones were successfully removed by laparoscopic ureterolithotomy using a single-use digital flexible ureteroscope. The patient had an uneventful recovery and remained well 1 month post-operation. CONCLUSIONS The application of single-use digital flexible ureteroscopes for laparoscopic ureterolithotomy has demonstrated safety, efficiency, and cost-effectiveness. The authors believe that it is a safe alternative for the removal of concurrent ureteral and renal stones, especially in patients with multiple comorbidities.

A 4 mm vesicoureteric junction stone causing rupture of pelvicoureteric junction - case report.

We discuss the case of a 67-year-old man who presented with a right-sided abdominal pain and on subsequent radiological imaging(s) in the form of an enhanced computed tomography scan of the abdomen and pelvis followed by a delayed excretory phase (computed tomography urogram), found to have a distal 4 mm vesicoureteric junction stone which had caused a pelvicoureteric junction rupture which was evident on extravasation of contrast. This warranted an urgent surgical intervention in the form of ureteric stent insertion. This case clearly depicts that with even a small stone associated with severe flank pain, rupture or pelvicoureteric junction/calyces should be suspected and we should never overlook symptoms and push for medical expulsive therapy in patients who do not appear to be septic or obstructed. This work has been reported in line with the Surgical CAse REport (SCARE) criteria.

Diagnostic evaluation of upper tract urothelial carcinoma: can we safely omit diagnostic ureteroscopy?

To identify clinicopathological or radiological factors that may predict a diagnosis of upper urinary tract urothelial cell carcinoma (UTUC) to inform which patients can proceed directly to radical nephroureterectomy (RNU) without the delay for diagnostic ureteroscopy (URS). All consecutive patients investigated for suspected UTUC in a high-volume UK centre between 2011 and 2017 were identified through retrospective analysis of surgical logbooks and a prospectively maintained pathology database. Details on clinical presentation, radiological findings, and URS/RNU histopathology results were evaluated. Multivariate regression analysis was performed to evaluate predictors of a final diagnosis of UTUC. In all, 260 patients were investigated, of whom 230 (89.2%) underwent URS. RNU was performed in 131 patients (50.4%), of whom 25 (9.6%) proceeded directly without URS - all of whom had a final histopathological diagnosis of UTUC - and 15 (11.5%) underwent RNU after URS despite no conclusive histopathological confirmation of UTUC. Major surgery was avoided in 77 patients (33.5%) where a benign or alternative diagnosis was made on URS, and 14 patients (6.1%) underwent nephron-sparing surgery. Overall, 178 patients (68.5%) had a final diagnosis of UTUC confirmed on URS/RNU histopathology. On multivariate logistic regression analysis, a presenting complaint of visible haematuria (hazard ratio [HR] 5.17, confidence interval [CI] 1.91-14.0; P = 0.001), a solid lesion reported on imaging (HR 37.8, CI = 11.7-122.1; P < 0.001) and a history of smoking (HR 3.07, CI 1.35-6.97; P = 0.007), were predictive of a final diagnosis of UTUC. From this cohort, 51 (96.2%) of 53 smokers who presented with visible haematuria and who had a solid lesion on computed tomography urogram had UTUC on final histopathology. We identified specific factors which may assist clinicians in selecting which patients may reliably proceed to RNU without the delay of diagnostic URS. These findings may inform a prospective multicentre analysis including additional variables such as urinary cytology.

The use of artificial intelligence and deep learning reconstruction in urological computed tomography: Dose reduction at ghost level

Abstract Objective: The objective of the study is to demonstrate that with the use of artificial intelligence (AI) in computed tomography (CT), radiation doses of CT kidney-ureter-bladder (KUB) and CT urogram (CTU) can be reduced to less than that of X-ray KUB and CT KUB, respectively, while maintaining the good image quality. Materials and Methods: We reviewed all CT KUBs (n = 121) performed in September 2019 and all CTUs (n = 74) performed in December 2019 at our institution. The dose length product (DLP) of all CT KUBs and each individual phase of CTU were recorded. DLP of each scan done with new scanner (Canon Aquilion One Genesis with AiCE [CAOG]) which uses AI and deep learning reconstruction (DLR) were compared against traditional non-AI scanner (GE OPTIMA 660 [GEO-660]). We also compared DLPs of both scanners against the United Kingdom, National Diagnostic Reference Levels (NDRL) for CT. Results: One hundred and twenty-one patient’s CT KUBs and 74 patient’s CTUs were reviewed. For CT KUB group, the mean DLP of 81/121 scans done using AI/DLR scanner (CAOG) was 77.8 mGy cm (1.16 mSv), while the mean DLP of 40/121 CT KUB done with GEO-660 was 317.1 mGy cm (4.75 mSv). For CTU group, the mean DLP for 46/74 scans done using AI/DLR scanner (CAOG) was 401.9 mGy cm (6 mSv), compared to mean DLP of 1352.6 mGy cm (20.2 mSv) from GEO-660. Conclusion: We propose that CT scanners using AI/DLR method have the potential of reducing radiation doses of CT KUB and CTU to such an extent that it heralds the extinction of plain film XR KUB for follow-up of urinary tract stones. To the best of our knowledge, this is the first study comparing CT KUB and CTU doses from new scanners utilizing AI/DLR technology with traditional scanners using hybrid iterative reconstruction technology. Moreover, we have shown that this technology can markedly reduce the cumulative radiation burden in all urological patients undergoing CT examinations, whether this is CT KUB or CTU.

EDITORIAL COMMENT

Unenhanced Computed Tomography (CT) is the gold standard for detection of urinary stones. An unenhanced phase is considered essential for a high-quality CT urogram. “Virtual unenhanced” CT scans (ie, CT scans with contrast that are computationally filtered to subtract out the contrast material) hold promise to reduce radiation exposure and expedite imaging studies. However, the technique has been limited by low sensitivity and poor ability to detect of small stones.

A descriptive study to analysis the ureteral length in adult population

Purpose: The ureteral stent is an essential in various urological procedures. Therefore, choosing an ideal ureteral stent is central to minimizing the incidence of stent related complications. This study aim was to identify the average length of ureteral in adult population as it would help to opt for optimal stenting according to the variability of age and gender. Materials and methods: It was a descriptive cross-sectional study at Teaching Hospital Jaffna and underwent to analysis the average length of ureteral among adults based on their CT urogram. This study was approved (Reg.No:S01/07/2021) on 30 September 2021 by the Ethics Review Committee of Teaching Hospital Jaffna and the patient informed written consent was received. A total number of 69 patients had been ordered for computed tomography urogram consecutively in last 4 months from 1st October 2021to 31st January 2022. All ureterals with pathological conditions were excluded from this study. The actual and linear lengths were calculated by using the Radiant DICOM viewer 3.2.3. Results: The gender distribution was men 69.6% and women 30.4%. Fifty seven (49.6%) were right ureterals and fifty eight (50.4%) were left ureterals. The average length of ureteral right and left were 23.03 (±3.15) cm and 23.48 (±3.17) cm respectively. The average length of right ureteral in male was 23.03 (±2.85) cm and left was 23.64 (±3.16) cm while it was estimated in female right 23.03 (±3.82) cm and left 22.98 (±3.26) cm. The multiple linear regressions showed that there is a no linear relationship between the ureteral length and age or gender. Conclusion: The average actual length of ureteral of Jaffna adult population is 23.03 (±3.15) cm in right and 23.48 (±3.17) cm in left. The median ureteral length is 23.26 (±3.15) cm. Therefore, it is prudent to use 24cm ureteral stent to Sri Lankan population.

Upper tract CT urogram for the surveillance of high-risk non-muscle invasive bladder cancer–are we over-screening patients?

Objective: The European Association of Urology (EAU) recommends annual upper tract imaging for high-risk (HR), non-muscle invasive bladder cancer (NMIBC). We evaluated the incidence of upper tract recurrence found during imaging surveillance for HR NMIBC and appraised our imaging strategy and patient radiation exposure. Subjects/patients (or materials) and methods: Two hundred and eighty-six patients between 2014 and 2019 with HR NMIBC (G3 tumour or T1 tumour or CIS, as per National Institute for Clinical Excellence (NICE) guidelines), were included in the study. The total number of computed tomography (CT) scans performed, the average radiation dose administered and the incidence rate of upper tract disease for each patient were recorded and analysed using a Microsoft Excel database. Results: The incidence rate of upper tract recurrence diagnosed during CT follow-up was 4/286 (1.4%). Three had a successful laparoscopic nephroureterectomy, the fourth was medically unfit for surgery. In total, 2.8% (8/286) were found to have other urological diagnoses. Patients received a CT scan on average every 13 months, with a mean radiation dose of 11.5 mSv. Conclusion: This study found that patients with HR NMIBC have a lower risk of upper tract recurrence than previously reported, which might support a guideline change to eliminate unnecessary radiation exposure during follow-up. Level of evidence: Not applicable for this multi-centre audit