Inflatable penile prosthesis (IPP): diagnosis of complications.

Inflatable penile prostheses are a common treatment for erectile dysfunction that is unresponsive to less-invasive measures. Complications can arise at the time of the placement of the prosthesis or at a later date. Complications may be related to infection and/or mechanical failure of one or more of the prosthesis components including cylinder, reservoir, pump, and tubing. Mechanical failure includes kinking, migration, and aneurysmal dilation of the cylinder, erosion of the tunica albuginea of the corpora cavernosum by the cylinder, disconnection of the tubing, and migration of the reservoir. MRI of the entire components with the cylinders in both flaccid and inflated states is the best imaging modality available to image patients with suspected implant complications.

Pearls and pitfalls in sonographic imaging of symptomatic urolithiasis in pregnancy.

Symptomatic urolithiasis in the pregnant patient presents a diagnostic challenge to the clinician and radiologist. The presentation can mimic multiple other disease processes, including pathology unique to the gravid patient. The objective of this article was to describe challenges in sonographic imaging of urolithiasis in pregnant patients.Ultrasonography is the imaging modality of choice in pregnant patients with suspected urolithiasis. Signs of urinary collecting system obstruction that are usually reliable in nonpregnant patients may not be reliable in pregnant patients. Normal physiological changes of pregnancy can mimic ureteral obstruction on imaging. Utilization of endovaginal scanning techniques and intrarenal resistive index determination may help improve the diagnostic accuracy of ultrasound in symptomatic patients.

Imaging evaluation of amyloidosis of the urinary tract and retroperitoneum.

Amyloidosis is a heterogeneous group of disorders and may be classified as systemic or localized on the basis of the distribution of amyloid deposition. Infrequently, the urinary tract and supporting retroperitoneum may be involved, and the imaging findings are nonspecific and diverse. Localized amyloidosis usually involves the bladder and often mimics malignancy. Less frequently, the ureter, renal pelvis, and urethra are involved. The most common findings of amyloid deposition are focal or diffuse wall thickening in the urinary tract with intramural calcification that often results in ureteral obstruction. When the renal parenchyma is involved, patients generally develop nephrotic-range proteinuria, and the kidneys appear atrophic with cortical thinning. In systemic amyloidosis, amyloid may infiltrate the retroperitoneal and pelvic soft tissues, encasing the urinary tract, with diffuse soft-tissue thickening and slowly progressive calcification. In both localized and systemic amyloidosis, amyloid lesions are characteristically hypointense at T2-weighted magnetic resonance imaging. Because myeloma or lymphoma is often present with systemic amyloidosis, biopsy is necessary to diagnose the condition. Amyloid lymphadenopathy characteristically appears as nodal enlargement with calcification and low attenuation at computed tomography. Radiologists should be familiar with the imaging features of amyloidosis that, in the appropriate clinical context, may indicate the diagnosis.

Percutaneous nephrolithotomy for large or multiple upper tract calculi and autosomal dominant polycystic kidney disease.

PURPOSE: Percutaneous nephrolithotomy is standard therapy for upper tract calculi larger than 2 cm. However, the role of percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease has not been well evaluated. We report our experience with percutaneous nephrolithotomy in patients with autosomal dominant polycystic kidney disease. MATERIALS AND METHODS: We retrospectively reviewed the charts of all patients with autosomal dominant polycystic kidney disease and subsequent renal calculi managed by percutaneous nephrolithotomy from October 1981 to the present. RESULTS: We identified 9 patients. Percutaneous nephrolithotomy was performed in 11 kidneys. Flank pain was the presenting symptom in 6 patients. Average stone burden was 2.5 cm (range 1.6 to 3.6). Two access tracts were necessary in 5 kidneys. No intraoperative complications occurred. In 2 kidneys a second stage endoscopic procedure with ultrasonic lithotripsy was required to achieve stone-free status. Nephrostogram 24 hours after the final procedure showed no residual stone fragments in 9 of 11 kidneys (82%). The remaining 2 patients underwent percutaneous basket extraction to render them stone-free. There were no postoperative complications or recurrent stones. No patient required blood transfusion. Mean followup was 2.7 years (range 0.3 to 4). Mean calculated creatinine clearance was stable at 85.6 (range 45.9 to 126.6) and 89.5 mg/dl per minute (range 39.6 to 126.6) preoperatively and at last followup, respectively (p = 0.783). CONCLUSIONS: Autosomal dominant polycystic kidney disease increased operative complexity, the need for multiple percutaneous access tracts and the likelihood of repeat endoscopy. Despite the altered anatomy percutaneous nephrolithotomy was a safe, efficacious approach for autosomal dominant polycystic kidney disease. At last followup there was no stone recurrence and renal function was stable.

Management of benign biliary strictures by percutaneous interventional radiologic techniques (PIRT).

INTRODUCTION: Some biliary strictures may be manageable by percutaneous interventional radiologic techniques (PIRT), but long-term efficacy of this approach is scarce. METHODS: We reviewed retrospectively all patients with biliary strictures secondary to traumatic bile duct injury or strictured bilioenteric anastomoses. Patients in whom the initial management was by PIRT from 1998 through 2003 were selected. Subjects with sclerosing cholangitis, hepatic transplantation, or malignant strictures were excluded. Data were obtained from medical records and/or direct patient contact. Comparisons were made by Fisher's exact test and Wilcoxon rank-sum test. RESULTS: Twenty-seven patients with biliary strictures were treated by PIRT. Mean age was 54 years (range 11-86). Most frequent etiology was laparoscopic cholecystectomy injury in 11 patients (41%). Eight patients (29%) had undergone biliary resection for malignancy, seven (26%) a pancreatoduodenectomy, and one for presumed ischemic cholangiopathy; no strictures were secondary to neoplastic recurrence. PIRT was successful in 10 of 11 patients (91%) with short, isolated bile duct strictures secondary to laparoscopic cholecystectomy and in seven of 15 patients (41%) with strictured bilioenteric anastomosis, but not in the patient with ischemic cholangiopathy. Twenty patients (74%) were stent-free at follow-up. Anastomotic biliary strictures were more likely to fail PIRT than isolated strictures secondary to laparoscopic cholecystectomy injury (p=0.02). CONCLUSION: Percutaneous balloon dilatation and stenting can be an effective strategy for patients with bile duct strictures, especially short bile duct strictures after laparoscopic cholecystectomy. Anastomotic strictures are associated with less good results when managed by PIRT but are successful in up to 40% of patients.

Percutaneous nephrolithotomy success in the transplant kidney.

PURPOSE: Treatment for symptomatic calculi in the transplanted kidney can be problematic. Percutaneous nephrolithotomy has routinely been used but concerns exist about potential injury to adjacent organs using a percutaneous access technique. We report our experience with percutaneous nephrolithotomy in the transplant kidney. MATERIALS AND METHODS: A retrospective chart review from 1988 to the present was performed of all cases of a renal transplant and subsequent renal calculi treated with percutaneous nephrolithotomy. RESULTS: We identified 13 patients with a renal transplant who underwent percutaneous nephrolithotomy. Presenting symptoms included renal failure in 46.1% of cases, hematuria in 23.1%, urinary tract infection/pyelonephritis in 23.1%, pain in 15.4%, fever in 7.7% and hydronephrosis in 7.7%. Average calculus size was 1.36 cm (range 0.2 to partial staghorn). A single access tract was used in 12 cases and 2 access tracts were used in 1. Ultrasonic lithotripsy was performed in 10 cases, basket extraction was performed in 3 and the 2 techniques were performed in 1. No intraoperative complications occurred. Nephrostogram 24 hours after the procedure demonstrated no residual fragments in 10 patients (76.9%). Repeat endoscopy was required in 3 patients to achieve subsequent stone-free status. Postoperative complications developed in 3 patients, including sepsis, gastrointestinal bleeding and herpes esophagitis, respectively. Mean followup was 5.3 years (range 0.6 to 9). The single stone recurrence was treated with shock wave lithotripsy. Mean creatinine was stable at 2.0 mg/dl (range 0.9 to 3.9) preoperatively to 1.7 mg/dl (range 0.9 to 2.6) at the last visit (p = 0.311). CONCLUSIONS: Percutaneous nephrolithotomy is safe and effective in the transplanted kidney. Minimal postoperative complications were noted and stone-free status was achieved in all cases. At long-term followup there were few stone recurrences with stable graft function after the procedure.

CT findings of walled-off pancreatic necrosis (WOPN): differentiation from pseudocyst and prediction of outcome after endoscopic therapy.

Computed tomography (CT) findings that may differentiate walled-off pancreatic necrosis (WOPN) from pancreatic pseudocyst were investigated. CT examinations performed before endoscopic therapy of pancreatic fluid collection (PFC) in 73 patients (45 WOPN, 28 pseudocysts) were evaluated retrospectively by two radiologists. PFC was evaluated for size, extension to paracolic space, characteristics of wall and internal structure. The pancreas was evaluated for deformity or discontinuity, and pancreatic duct dilation. CT findings that were associated with WOPN or pseudocyst were identified. CT score (number of CT findings associated with WOPN minus number of findings associated with pseudocyst) was calculated for each PFC. PFC was categorized as WOPN or pseudocyst using a CT score threshold. Larger size, extension to paracolic space, irregular wall definition, presence of fat attenuation debris in PFC, pancreatic deformity or discontinuity (P < 0.05-0.0001) were findings associated with WOPN. Presence of pancreatic duct dilation was associated with pseudocyst. Using a CT score of 2 or higher as a threshold, CT differentiated WOPN from pseudocyst with an accuracy of 79.5-83.6%. Thus, CT can differentiate WOPN from pseudocysts.

Neonatal thyroid function after administration of IV iodinated contrast agent to 21 pregnant patients.

OBJECTIVE: The objective of our study was to document neonatal thyroid function after in utero exposure to nonionic iodinated contrast material to determine the potential risk of subsequent neonatal hypothyroidism. MATERIALS AND METHODS: We identified pregnant patients ("maternal patient") who underwent CT with iodinated IV contrast material between February 2000 and October 2006. The specifics of the CT examinations were reviewed including patient age, gestational age of conceptus at time of exposure, type of CT, and type and dose of contrast agent. The neonatal serum thyroid-stimulating hormone (TSH) level obtained from the exposed infant ("neonatal patient") was retrieved from the Minnesota Department of Health. RESULTS: Twenty-one patients gave us consent to review the requested data concerning their 23 children (two mothers had twins). Mean maternal age at the time of CT was 29 years (range, 19-41 years). Mean gestational age (based on last menstrual period) at the time of CT was 23 weeks (range, 8-37 weeks). Neonatal patients were born at a mean of 38 weeks of gestation (range, 24-41 weeks of gestation). Serum TSH was collected at a mean of 43 hours after delivery (range, 24-70 hours). For all neonatal patients, serum TSH levels were normal. Mean serum TSH was 9.7 muIU/mL (range, 2.2-28.8 muIU/mL). No maternal patient reported thyroid trouble in her child. CONCLUSION: Based on neonatal TSH measurements in a small number of patients, we found no ill effect of iodinated contrast agents on neonatal thyroid function after in utero exposure.

Long-term outcomes of percutaneous nephrolithotomy compared to shock wave lithotripsy and conservative management.

PURPOSE: Percutaneous nephrolithotomy is successful at achieving stone-free status but long-term safety data are lacking. We report our long-term experience with percutaneous nephrolithotomy and compare these results with other treatment modalities. MATERIALS AND METHODS: We identified 87 patients treated with percutaneous nephrolithotomy from 1983 to 1984 who continue to receive care at our institution. Retrospective chart review was performed. Long-term results were compared to those of a group of 288 patients with stones treated nonsurgically (controls) and a group of 288 patients treated with shock wave lithotripsy followed for 19 years. RESULTS: Average followup was 19.2 years (range 12.7 to 23.0). After percutaneous nephrolithotomy new onset renal insufficiency was noted in 9 patients (10.6%), hypertension in 29 (34.1%), diabetes mellitus in 20 (23.5%) and ureteropelvic junction obstruction in 3 (3.5%). Stone recurrence occurred in 32 patients (36.8%). Recurrent stone events were associated with residual fragments after percutaneous nephrolithotomy (p = 0.049). Compared to shock wave lithotripsy there were no significant differences in the development of renal insufficiency, hypertension or diabetes mellitus. Stone recurrence was more common following shock wave lithotripsy (53.5%) compared to percutaneous nephrolithotomy (p = 0.033). Compared to controls there were no significant differences in the development of renal insufficiency or hypertension. On univariate analysis percutaneous nephrolithotomy was associated with the development of diabetes mellitus (p <0.001) but this association did not persist in multivariate analysis. CONCLUSIONS: At 19 years of followup stone recurrences were less frequent following percutaneous nephrolithotomy compared to shock wave lithotripsy. Recurrent stone events were associated with residual fragments after percutaneous nephrolithotomy. Percutaneous nephrolithotomy was not associated with the development of adverse medical conditions compared to shock wave lithotripsy or conservatively managed stone cases.

Imaging of the male urethra.

For imaging of the male urethra, conventional radiographic contrast studies including retrograde urethrography are most commonly utilized. They are best suited for delineating luminal abnormalities of the urethra and thus are commonly used as the primary imaging modality for patients with various urethral abnormalities such as trauma, inflammation, and stricture. More recently, the cross-sectional imaging techniques of ultrasound, computed tomography and magnetic resonance imaging have been utilized increasingly for urethral and periurethral abnormalities. These studies are most valuable as an adjunctive tool in patients with the complex anatomical derangements such as congenital anomalies, posterior (or bulbomembranous) urethral injuries, and with urethral or periurethral tumors. These cross-sectional techniques can be performed during micturition or with retrograde injection of saline or jelly through the urethral meatus to improve visualization of the urethral luminal abnormalities. This article describes imaging techniques, anatomy, and findings of various urethral and periurethral pathology in the male including congenital anomalies, infection/inflammation, stricture, traumatic injury, fistula, tumors, and calculi.

Radiation exposure and pregnancy: when should we be concerned?

The potential biological effects of in utero radiation exposure of a developing fetus include prenatal death, intrauterine growth restriction, small head size, mental retardation, organ malformation, and childhood cancer. The risk of each effect depends on the gestational age at the time of exposure, fetal cellular repair mechanisms, and the absorbed radiation dose level. A comparison between the dose levels associated with each of these risks and the estimated fetal doses from typical radiologic examinations lends support to the conclusion that fetal risks are minimal and, therefore, that radiologic and nuclear medicine examinations that may provide significant diagnostic information should not be withheld from pregnant women. The latter position is advocated by the International Commission on Radiological Protection, National Council on Radiation Protection, American College of Radiology, and American College of Obstetrics and Gynecology. However, although the risks are small, it is important to ensure that radiation doses are kept as low as reasonably achievable.

Factors associated with increased survival after photodynamic therapy for cholangiocarcinoma.

BACKGROUND & AIMS: Recent studies have shown a survival advantage using photodynamic therapy (PDT) in patients with unresectable cholangiocarcinoma. Factors associated with increased survival after PDT are unknown. METHODS: Twenty-five patients with cholangiocarcinoma who were treated with PDT at the Mayo Clinic Rochester from 1991 to 2004 were studied. Porfimer sodium (2 mg/kg) was administered intravenously to patients with Bismuth type I (3 patients), type III a/b (13 patients), and type IV (9 patients) tumors. Forty-eight hours later, PDT was administered using a 1.5- to 2.5-cm diffusing fiber that was advanced across the tumor by either retrograde (20 patients) or percutaneous (5 patients) cholangiography. Laser light was applied for a total energy of 180 J/cm2 in 1-3 applications. Patients received PDT treatments every 3 months. Plastic biliary stents (10-11.5 F) were inserted to decompress the biliary system after PDT. Survival analysis was performed using Kaplan-Meier curves and Cox proportional hazards models. RESULTS: Patients were 64 (standard error of the mean, +/-2.6) years of age; 20 (80%) were men. The median overall survival period was 344 days. The median survival period after PDT was 214 days. The 1-year survival rate was 30%. On multivariate analysis, the presence of a visible mass on imaging studies (hazard ratio, 3.55; 95% confidence interval, 1.21-10.38), and increasing time between diagnosis and PDT (hazard ratio, 1.13; 95% confidence interval, 1.02-1.25) predicted a poorer survival rate after PDT. A higher serum albumin level (hazard ratio, 0.16; 95% confidence interval, 0.04-0.59) predicted a lower mortality rate after PDT. CONCLUSIONS: Patients with unresectable cholangiocarcinoma without a visible mass may benefit from earlier treatment with PDT.

Long-term success of antegrade endopyelotomy compared with pyeloplasty at a single institution.

BACKGROUND AND PURPOSE: The classic standard for surgical repair of ureteropelvic junction (UPJ) obstruction has been open pyeloplasty, with a 95% success rate. Antegrade endopyelotomy is a less-invasive option with a slightly lower success rate. However, recent data call into question the long-term durability of UPJ repair. We present the long-term success of treatment of UPJ obstruction comparing these two modalities. PATIENTS AND METHODS: We reviewed the medical records of patients undergoing percutaneous antegrade endopyelotomy or open and laparoscopic pyeloplasty for UPJ repair in our practice from 1988 to 2004. Success was defined as both radiographic and symptomatic improvement. We evaluated the impact of preoperative factors, including prior surgical repair, crossing vessels, renal function, and calculi, on success. RESULTS: The estimated 3-, 5-, and 10-year recurrence-free survival rates for the endopyelotomy group (N = 182) were 63%, 55%, and 41%, respectively, compared with 85%, 80%, and 75% for the pyeloplasty group (N = 175; P < 0.001). Of the failed endopyelotomies undergoing salvage open repair, 8 of 26 (31%) had crossing vessels. Poor renal function and previous failed pyeloplasty decreased success in the pyeloplasty group. Variation from standard cold-knife incision adversely affected endopyelotomy success. CONCLUSIONS: Long-term success rates after both endopyelotomy and pyeloplasty are worse than previously reported. Although most failures in both groups occurred within 2 years, failures continue to appear after 5 and 10 years, and patients should be followed accordingly. In view of these results of endopyelotomy, laparoscopic pyeloplasty may prove to be the preferred minimally invasive approach to repair UPJ obstruction.

Three-dimensional CT virtual endoscopy in the detection of simulated tumors in a novel phantom bladder and ureter model.

BACKGROUND AND PURPOSE: Cystoscopy and ureteroscopy have limitations in the evaluation for urothelial tumors, and both are invasive. We studied the utility of three-dimensional (3D) CT virtual endoscopy in phantom models. MATERIALS AND METHODS: A phantom pelvis was constructed of Plexiglas, porcine pelvic bones, and processed animal fat and scanned at various table speeds in a four detector-row CT machine for ability to detect "tumors" of Solidwater plastic polymer. Images were reconstructed at slice thicknesses of 2.5 to 5.0 mm and reconstructed in 3D for evaluation by two radiologists with no knowledge of the scanning parameters or tumor location. Similar studies were performed with a ureter model. RESULTS: With 5-mm slices, the sensitivity for bladder tumors ranged from 67% for 2-mm tumors to 100% for 4-mm tumors, with 12 false-positive findings. The overall sensitivity was 86% with 3.75-mm slices with one false positive, and with 2.5-mm slices, the sensitivity was 93%, again with one false positive. For the ureteral tumors, the overall sensitivities and numbers of false positives were 88.9% and eight with 5.0-mm collimation, 88.9% and four with 3.75-mm collimation, and 100% and three with 2.5-mm collimation. The effective radiation dose for all studies was equivalent to that of a standard abdomen/pelvis scan. CONCLUSIONS: Although virtual endoscopy traditionally has had difficulty detecting tumors <5 mm, the multidetector-row CT protocols used in this study could detect most lesions smaller than this. The scan also depicts the other tissues of the pelvis, which is valuable for staging. The 3D images were produced using data from the CT urogram parameters standard at our institution.

Urinary matrix calculi: our experience at a single institution.

PURPOSE: Matrix stones are an uncommon form of urinary calculi and may be mistaken for tumors involving the renal collecting system, thereby presenting a diagnostic and therapeutic dilemma to the practicing urologist. MATERIALS AND METHODS: From 1980 to 2003 we identified 5 patients with urinary matrix stones referred to our tertiary medical center for evaluation and treatment. RESULTS: All 5 cases had complex clinical and radiographic features at presentation. We outline the clinical presentations, imaging findings and management, and review the literature of matrix stone disease. CONCLUSIONS: A high index of suspicion is required in diagnosing matrix calculi in addition to carefully selected radiographic imaging. Due to their variable appearance in standard radiological studies, the evaluation of matrix stones may require invasive techniques such as ureteroscopy for accurate diagnosis. Percutaneous removal is the primary treatment modality to render patients stone-free.

Detection of crossing vessels as the cause of ureteropelvic junction obstruction: the role of antegrade pyelography prior to endopyelotomy.

PURPOSE: To review the utility of antegrade pyelography in detecting crossing vessels as the cause of uretero-pelvic junction (UPJ) obstruction prior to planned endopyelotomy. MATERIALS AND METHODS: A retrospective review of the medical records, surgical reports, and medical images was performed in 109 consecutive adult patients in our practice who underwent antegrade pyelography just prior to planned endopyelotomy for symptomatic UPJ obstruction between January 1996 and December 2002. RESULTS: Fourteen patients were identified in whom a specific antegrade pyelographic appearance was detected in the diagnosis UPJ obstruction caused by crossing vessels. Surgical plans were changed in all 14 patients from antegrade endopyelotomy to open surgical pyeloplasty, during which the anterior (ventral) crossing vessels causing obstruction were confirmed. An additional three patients in the reviewed endopyelotomy group clinically failed their initial endopyelotomy procedure and were shown at the time of subsequent open or laparoscopic reconstructive surgery to have UPJ obstruction caused by anterior crossing vessels, but that diagnosis was missed at the time of the initial antegrade pyelogram. CONCLUSION: A specific antegrade pyelographic appearance was identified to diagnose UPJ obstruction caused by anterior crossing vessels with a sensitivity of 82.4% and a specificity of 100%. The direct obstructing effect of the vessels on the ureter is defined with pyelography as an acute posteriorly angulated ureteral deformity just below a patent UPJ. Recognition of this specific antegrade pyelographic appearance permits use of an appropriate surgical technique for UPJ obstruction repair.

Percutaneous ultrasonic lithotripsy (PUL) after shock wave lithotripsy (SWL) failure.

OBJECTIVE: Shock wave lithotripsy (SWL) is an attractive initial treatment for nephrolithiasis. Unfortunately, a significant number of stones are resistant to SWL therapy and require subsequent percutaneous ultrasonic lithotripsy (PUL) for definitive treatment. Our objective was to determine if previous SWL had adverse effects on PUL success and if there were differences between the patients undergoing primary PUL and those undergoing PUL after SWL failure. MATERIALS AND METHODS: In 2001, 108 PULs were performed at our institution, of which 40 (37%) were performed after SWL failure. Stone location, anesthesia time, stone composition and size, and complication rates were compared between patients who had PUL alone and those who underwent PUL after SWL failure. Anesthesia time was considered a reflection of technical difficulty of the case. RESULTS: Stone composition differed between the SWL failure and primary PUL groups. Cystine stones were found to be more common in the ESWL failure group and calcium oxalate monohydrate stones more common in the primary PUL group. There was not a statistically significant difference in stone size, anesthesia time or complication rates, between the PUL alone and PUL after SWL failure groups. CONCLUSION: PUL remains a reliable and safe treatment of nephrolithiasis. Prior SWL does not affect efficacy, technical difficulty, or postoperative complications of subsequent PUL. Based on our data, prior SWL should not be considered a negative factor in PUL outcomes. Stone composition should be considered a prognostic indicator of SWL failure and alert the surgeon that primary PUL may be indicated.

Imaging of urethral disease: a pictorial review.

Retrograde urethrography and voiding cystourethrography are the modalities of choice for imaging the urethra. Cross-sectional imaging modalities, including ultrasonography, magnetic resonance (MR) imaging, and computed tomography, are useful for evaluating periurethral structures. Retrograde urethrography is the primary imaging modality for evaluating traumatic injuries and inflammatory and stricture diseases of the male urethra. Sonourethrography plays an important role in the assessment of the thickness and length of bulbar urethral stricture. Although voiding cystourethrography is frequently used to evaluate urethral diverticula in women, MR imaging is highly sensitive in the demonstration of these entities. MR imaging is also accurate in the local staging of urethral tumors.

CT urography.

With the recent introduction of multi-detector row helical computed tomography (CT), the radiologic evaluation of patients with urologic disease has changed rapidly. Two major approaches to CT urography have been developed. The first approach combines axial CT with timed excretory urography (EU) performed by using conventional radiography, digital radiography, or CT scanned projection radiography (SPR). This approach produces traditional projection urograms, and the timed imaging technique is familiar to radiologists and clinicians. Additional excretory phase CT can be performed when the EU findings are positive or indeterminate. Improved CT SPR processing technology produces radiographlike images, thus eliminating patient transportation between the CT and urography suites or the necessity for a CT suite with a ceiling-mounted x-ray tube and a modified CT tabletop for performance of EU. The second approach to CT urography combines axial CT with thin-section excretory phase CT. The near-isotropic volume data set enables creation of high-resolution two- and three-dimensional reformatted images. However, the increased amount of radiation and the time required for data manipulation are concerns. Further studies evaluating large numbers of patients with various urothelial abnormalities will be necessary to determine the optimal CT urography technique for clinical practice.