Chow et al.

Genitourinar y Imaging • Original Research

Split-Bolus MDCT
Urography

Split-Bolus MDCT Urography with

Synchronous Nephrographic and
Excretory Phase Enhancement
Lawrence C. Chow1,2 OBJECTIVE. Our purpose was to evaluate the utility of CT urography performed using a
Sharon W. Kwan1 split contrast bolus that yields synchronous nephrographic and excretory phase enhancement.
Eric W. Olcott1,3 MATERIALS AND METHODS. Five hundred consecutive patients referred for evalua-
Graham Sommer1 tion of possible urinary tract abnormalities (327 for painless hematuria) underwent CT urogra-
phy with unenhanced scanning of the abdomen and pelvis and scanning during concurrent
Chow LC, Kwan SW, Olcott EW, Sommer G nephrographic and excretory phase enhancement produced by administration of a split contrast
bolus. The enhanced abdomen scan was obtained with abdominal compression; the enhanced
pelvis scan was obtained after release of compression. Findings from axial sections and coronal
maximum intensity projections were correlated with clinical follow-up and, as available, with
laboratory and other imaging studies including cystoscopy, ureteroscopy, urine cytology, sur-
gery, and pathology. Follow-up management for each patient was determined by the clinical
judgment of the referring physician.
RESULTS. CT urography identified 100% of pathologically confirmed renal cell carcino-
mas (n = 10) and uroepithelial malignancies involving the renal collecting system or ureter
(n = 8). An additional nine renal masses were identified for which no pathologic proof has yet
been obtained, including eight subcentimeter solid renal masses and one multiloculated lesion.
Fourteen of 19 confirmed cases of uroepithelial neoplasm involving the bladder were identi-
fied. CT urography yielded one false-positive for bladder tumor, two false-positives for ureteral
tumor, and one patient with a bladder mass who refused further evaluation. CT urography
yielded sensitivity and specificity of 100% and 99% and 74% and 99% and positive predictive
value and negative predictive value of 80% and 100% and 93% and 99% for the renal collecting
system and ureter and bladder, respectively. CT urography was ineffective in identifying 11
cases of noninfectious cystitis. CT urography also depicted numerous other congenital and ac-
quired abnormalities of the urinary tract.
CONCLUSION. Split-bolus MDCT urography detected all proven cases of tumors of the
upper urinary tract, yielding high sensitivity and specificity. The split-bolus technique has the po-
Keywords: bladder, CT, kidney, ureter, urography
tential to reduce both radiation dose and the number of images generated by MDCT urography.
DOI:10.2214/AJR.07.2288
onventional excretory urography pered by poor depiction of the renal collecting
Received June 3, 2005; accepted after revision
March 22, 2007.

1Department of Radiology, Stanford University School of

Medicine, Stanford, CA.
2Present address: Department of Radiology, Oregon Health
and Science University, MC L340, 3181 SW Sam Jackson
Park Rd., Portland, OR 97201. Address correspondence to
L. C. Chow (chowl@ohsu.edu).
3Department of Radiology, VA Palo Alto Health Care
System, Palo Alto, CA.
AJR 2007; 189:314–322
0361–803X/07/1892–314
© American Roentgen Ray Society
C (EU) has for many decades been the
standard for the imaging evaluation
of the upper urinary tract. In recent
years, however, cross-sectional imaging tech-
niques have rapidly supplanted EU for many in-
dications. Currently, the only remaining major
application for the venerable EU is in the evalu-
ation of patients with painless hematuria, prima-
rily for the detection of upper urinary tract ma-
lignancy. Although EU remains a good method
for imaging the urothelium, it is clearly inferior
to cross-sectional imaging techniques such as
CT for evaluating the renal parenchyma.
The application of CT, however, in the
evaluation of the urothelium has been ham-
system and ureters by various factors, includ-
ing limited longitudinal resolution, poor uri-
nary tract distention, and obscuration of the
urothelium by dense excreted contrast mate-
rial. With current advances in MDCT and
careful attention to the specifics of CT proto-
col design, each of these obstacles is sur-
mountable. Early work in this area has shown
that it is possible to combine the benefits of
EU with those of cross-sectional imaging into
a single CT study termed “CT urography,”
which depicts both the renal parenchyma and
the collecting system and ureters [1–5].
Published work in this area has used the
capabilities of MDCT scanners to image the

314 AJR:189, August 2007


TABLE 1: MDCT Urography Technique
Phase Compression
Unenhanced abdomen and pelvis None
Contrast-enhanced abdomen Inflated
Contrast-enhanced pelvis After release Iliac crests to symphysis pubis 4 x 2.5 mm; 2.5-mm recon;
Note—LightSpeed QX/i and LightSpeed Ultra are manufactured by GE Healthcare. recon = reconstruction.
A B
abdomen with thin sections before and after
contrast administration during corticomed-
ullary, nephrographic, and excretory phases,
often resulting in three or four imaging
passes during the course of a single exami-
nation [2, 3, 5]. Clearly, such methods raise
concern for the total radiation dose being
imparted to patients and also result in large
numbers of axial source images that must be
interpreted. The purpose of this study was to
evaluate the utility of a split-bolus CT urog-
raphy technique that depicts the kidneys
during synchronous nephrographic and ex-
cretory phases, reducing the number of im-
aging passes required per examination, for
the detection of urinary tract malignancy
and other potential causes of hematuria.
Materials and Methods
Study Population
The study population consisted of 500 consec-
utive patients (189 women, 311 men; mean age,
55 years) undergoing MDCT urography during a
36-month period from April 2000 through March
2003. Twenty patients underwent two examina-
tions each, resulting in a total of 520 examina-
tions performed during this period. Three hun-
dred twenty-seven patients were referred for
painless hematuria, 33 for known or suspected
AJR:189, August 2007
Split-Bolus MDCT Urography
Coverage LightSpeed QX/i
Diaphragm to symphysis pubis 4 x 3.75 mm; 5-mm contiguous recon; 8 x 2.5 mm; 5-mm contiguous recon;
pitch, 1.5 (HiSpeed mode)
Diaphragm to iliac crests 4 x 2.5 mm; 2.5-mm recon;
1.25-mm interval; pitch, 1.5 (HiSpeed) 0.6-mm interval; pitch, 1.35
1.25-mm interval; pitch, 1.5 (HiSpeed) 1.25-mm interval; pitch, 1.35
urinary tract calculi, 32 for hematuria with flank
or back pain, 15 for hematuria with dysuria, 22
for evaluation of known renal lesions, 14 for pos-
sible urinary tract obstruction, five with pelvic
pain, 14 with chronic or recurrent urinary tract in-
fection, 14 with history of prior urinary tract ma-
lignancy, and 24 with other miscellaneous indica-
tions. Although referring physicians are urged to
use CT urography primarily as a tool for evalua-
tion of painless hematuria, it is not unexpected
that requests for the study are made in other clin-
ical settings. This research was performed under
an institutional review board–approved protocol.
MDCT Urography Acquisition Technique
All CT urography was performed on LightSpeed
MDCT scanners (4-MDCT LightSpeed QX/i or 8-
MDCT LightSpeed Ultra, GE Healthcare) using
similar techniques (Table 1).
All patients were asked to drink 900 mL of wa-
ter while in the waiting area approximately 20
minutes before scanning. IV contrast material
(Omnipaque 300 [iohexol], GE Healthcare) was
administered with a split-bolus technique as fol-
lows: 40 mL was administered at a rate of 2 mL/s
after the unenhanced phase. After a 4-minute de-
lay, an additional 80 mL was administered at 2
mL/s and the abdominal compression device was
inflated. The contrast-enhanced, breath-hold ab-
LightSpeed Ultra
pitch, 1.35
8 x 1.25 mm; 1.25 mm recon;
8 x 1.25 mm; 2.5 mm recon;
Fig. 1—CT urogram in 41-year-old man with
microhematuria. No cause for hematuria was
identified in this patient.
A and B, Maximum-intensity-projection (MIP) images
from normal CT urogram show areas of peristalsis within
ureters (arrows, B) resulting in undulating appearance
of ureteral contours. Abdominal data set (A) was
acquired with abdominal compression in place; pelvic
data set (B) was acquired after release of compression.
Small amount of overlap between two acquisitions
ensures that there are no gaps in coverage resulting
from slight differences in breath-hold.
dominal phase images were acquired 120 seconds
after the second contrast bolus, yielding images
in synchronous nephrographic and excretory
phases of enhancement. Subsequently, the com-
pression device was removed, and contrast-en-
hanced pelvic images were obtained to show the
pelvic ureters. A small overlap in coverage of the
abdominal and pelvic phase images was pre-
scribed to ensure that there were no gaps in cov-
erage resulting from slight changes in the degree
of inspiration between the two breath-holds. Dig-
ital scout images were obtained before the unen-
hanced phase and immediately after the contrast-
enhanced abdomen and pelvis phases.
Image Reconstruction
In addition to axial images, coronally refor-
matted maximum-intensity-projection (MIP) and
average-intensity-projection images were gener-
ated in all cases as follows. Individual thick-slab
MIP and average-intensity-projection images of
the enhanced right and left kidneys and proximal
ureters in a double-oblique plane truly coronal to
the kidneys were generated. Enhanced thick-slab
MIP and average-intensity-projection images in-
cluding both kidneys and ureters were generated
(Fig. 1). Stacks of sliding thin-slab MIP images
(5-mm thick, 2-mm overlap) in a double-oblique
plane truly coronal to the kidneys were generated
315
 Chow et al.

were ultimately diagnosed after the initial workup.

The retrospective review of the medical chart was
performed in part by all four authors. Mean follow-
up duration was 468 days with a median follow-up
duration of 433 days. Sensitivity, specificity, and
positive and negative predictive values of MDCT
urography were calculated for the detection of
pathologically proven urothelial malignancies.

Results
Urothelial Tumors
Nineteen of 27 pathologically proven
urothelial tumors of the urinary tract were de-
A B tected with MDCT urography. Sensitivity and
specificity for detection of upper tract urothelial
tumors were 100% and 99%, respectively, in-
cluding the pelvicaliceal system (n = 5) (Figs. 2
and 3) and ureters (n = 3) (Fig. 4). Positive and
negative predictive values for upper tract
urothelial tumors were 80% and 100%, respec-
tively. Upper tract tumors ranged in size from 3
mm to 2.7 cm, with a mean diameter of 1.7 cm.
In no cases were tumors of the pelvicaliceal
system or ureters discovered with other studies
or during the course of clinical follow-up in the
setting of a negative MDCT urogram.
Two ureteral tumors were identified on
MDCT for which no pathologic confirmation
has been obtained: one patient was a poor surgi-
cal candidate (a complex aortic dissection was
found incidentally during the same study) and
the other had a retrograde pyelogram and ure-
teroscopy that showed a frondlike lesion consis-
tent with hypertrophic inflammatory changes,
and thus no biopsy was performed. These le-
sions were not included in the final calculation
C D
of sensitivity and specificity because no patho-
Fig. 2—79-year-old man with new onset of painless hematuria and infundibular transitional cell carcinoma. logic proof was available.
A and B, Axial (A) and sagittal (B) images of right kidney from CT urography show method of prescribing
double-oblique plane, coronal to kidney, from which sliding thin-slab maximum-intensity-projection (MIP) MDCT urography resulted in two false-
images are generated. positive findings for a ureteral tumor. In one
C and D, Coronal thin-slab MIP images show circumferential mass encasing upper pole infundibulum (arrows). case, circumferential wall thickening of the
distal left ureter yielded only inflammatory
changes on repeated ureteroscopic biopsy
from both unenhanced and contrast-enhanced ity, GE Healthcare) by one of six attending radiol- (Fig. 5). In the second case, a ureteral filling
data sets (Fig. 2). Thick slab coronal and sagittal ogists in the abdominal imaging section with a min- defect was thought to be a papillary tumor on
MIP and average-intensity-projection images of imum of 6 years of experience in interpreting ureteroscopy, but on biopsy, the tissue was
the pelvic ureters were generated. abdominal CT. Images were viewed with different consistent with a scar.
Additional reformatting with volume render- window and level settings appropriate for evalua- The majority of the urothelial tumors were
ing and curved planar reformation was performed tion of the renal parenchyma or for the collecting located within the urinary bladder (Fig. 6), and
on occasion on an as-needed basis but was not structures and ureters. The results of MDCT urog- all five false-negative findings were for bladder
performed routinely. All image reconstructions raphy were retrospectively compared with the re- tumors. In all, there were 19 tumors of the blad-
were generated on an Advantage Workstation sults of other imaging examinations such as cystos- der, of which 14 were detected on MDCT urog-
(GE Healthcare). copy; retrograde studies and ureteroscopy; raphy, with a mean diameter of 2.9 cm and a
laboratory studies including urine cytology; and, range of 1.6–4.7 cm. Missed tumors were all
Image Interpretation and Clinical Follow-Up when available, surgery and pathology. In patients less than 5 mm. Of these, 14 were pathologi-
All images, including axial source images and who had a negative workup, clinical follow-up was cally confirmed transitional cell carcinoma, two
all reconstructions, were primarily interpreted in obtained through review of patient medical records were papillomas, and three had unproven pa-
soft-copy format on a PACS workstation (Centric- to determine whether urinary tract abnormalities thology but were confirmed on cystoscopy.

316 AJR:189, August 2007

 Split-Bolus MDCT Urography

Fig. 5—48-year-old man with history of bladder

transitional cell carcinoma. Patient had undergone
resection and bacille Calmette–Guérin (BCG)
treatment with negative cystoscopy. Axial image from
CT urography shows circumferential thickening of
distal left ureter (open arrows) with periureteric
stranding, thought to represent recurrent tumor, and
normal right ureter (arrow). Ureteroscopy revealed
A B stricture in this region with no visible tumor.
Ureteroscopic biopsy of this region, performed on two
Fig. 3—75-year-old woman with intermittent gross painless hematuria. separate occasions 2 years apart, revealed only
A and B, Coronal maximum-intensity-projection (MIP) images of right kidney show soft-tissue mass (open arrows) inflammatory changes with no carcinoma. Follow-up
filling lower pole calyx and infundibulum with extension into renal pelvis (black arrow, A). Patient underwent right imaging over past 4 years has shown no significant
nephroureterectomy, which revealed invasive transitional cell carcinoma. change in appearance of this stricture.

A B
Fig. 6—70-year-old man with painless hematuria. Axial
Fig. 4—Ureteral transitional cell carcinoma. image from CT urography shows pedunculated mass
A, Axial image from CT urography shows irregular lobulated filling defect (arrows) within distal right ureter in 85- (white arrow) with narrow, stalklike attachment (open
year-old man with painless hematuria. Ureteroscopy confirmed finding and patient underwent ureterectomy with arrow) arising from bladder trigone near left ureteral
reimplantation. Pathology revealed high-grade transitional cell carcinoma with invasion into muscularis propria. orifice. Transurethral resection revealed high-grade
B, Oblique maximum-intensity-projection (MIP) image from CT urography in 72-year-old man with ureteral papillary transitional cell carcinoma. Small filling
transitional cell carcinoma shows soft-tissue filling defect within distal left ureter (solid arrows). Contracted defect (black arrow) medial to right ureteral orifice
segment of ureter from peristalsis (open arrow) is also seen. represents normal interureteric ridge and should not
be mistaken for tumor. Although bladder tumors can be
seen with CT urography, its sensitivity remains low and
it should not be substituted for cystoscopy.

There was one false-positive for a bladder tumor
in which the mass turned out to be an enlarged
prostate on cystoscopy. For the urinary bladder,
MDCT urography yielded 74% sensitivity,
99.8% specificity, positive predictive value of
93%, and negative predictive value of 99%.
Renal Cell Carcinoma
Ten of 10 pathologically confirmed renal cell
carcinomas (Fig. 7) were identified by MDCT
urography, yielding a sensitivity of 100%. The
mean size of the neoplasms was 4.6 cm with a
range of 1.6–14.0 cm. Seven of these patients
were ultimately staged at T1 N0 M0, two at T2
N0 M0, and one at T3a N0 M0. One of these pa-
tients had undergone sonography only 16 days
earlier, which showed normal kidneys. Two pa-
tients underwent intraoperative laparoscopic
sonography that confirmed the presence of a re-

AJR:189, August 2007 317

 Chow et al.

A B
Fig. 7—42-year-old man with one episode of gross, painless hematuria and right renal cell carcinoma.
A, Coronal thick-slab maximum-intensity-projection (MIP) image from CT urography performed on 4-MDCT
scanner, which simulates conventional excretory urography, shows no abnormality because of small size of mass,
which does not deform lateral renal contour or renal collecting system.
B, Sagittal image from CT urography clearly shows mass (arrows) involving anterior upper pole.

nal tumor. In one patient, pathologically con-
firmed synchronous renal cell and transi-
tional cell carcinomas were identified.
Eight additional small solid renal masses
(all < 1 cm) with radiologic appearances
consistent with renal cell carcinoma were
identified on MDCT urography in six pa-
tients (two had bilateral lesions). No patho-
logic proof has been obtained for these
cases because the patients were either poor
surgical candidates or opted for conserva-
tive management. The presence of one
small renal lesion worrisome for malig-
nancy on MDCT urography could not be
confirmed with additional imaging workup.
In this patient with underlying polycystic
kidney disease, a 12-mm exophytic renal
lesion appeared to enhance by 25 H. Nei-
ther transabdominal nor intraoperative
sonography showed a solid renal mass.
Urolithiasis
Renal calculi were identified in a total of
95 patients on MDCT urography. Although
the majority of stones were small, measuring
less than a centimeter in maximal diameter,
three patients had a staghorn calculus. In 33
patients, stones were identified within the
ureters or renal pelves. Four stones were in
the renal pelvis, two in the proximal ureter,
eight in the mid ureter, and 19 in the distal
ureter or at the ureterovesical junction. In two
patients, stones were present within partially
duplicated ureters. Interestingly, both were
seen at the junction of the duplicated proxi-
mal ureters where they coalesced into a single
distal ureter. Four stones were found in the
bladder. Five patients had medullary nephro-
calcinosis (Fig. 8). All of these stones were
identified on the unenhanced CT images. No
false-negative CT urograms were identified in
which a stone was detected either clinically or
Fig. 8—24-year-old man with flank pain. Curved planar
by other imaging techniques after a negative reformation image through left kidney and ureter from
CT urogram was obtained. unenhanced scan shows medullary nephrocalcinosis,
multiple calculi, within distal left ureter (solid arrow);
Congenital Anomalies ureteral thickening; and extensive periureteric
stranding (open arrows).
MDCT urography showed congenital
anomalies in 15 patients. Duplication of the
right collecting system was seen in five pa- tional cell carcinoma (n = 3), horseshoe kid-
tients (Fig. 9), the left collecting system in ney (n = 1), postsurgical (n = 5), postin-
seven patients, and bilateral duplication in flammatory (n = 1), prostatic hypertrophy
two patients. Two patients had a horseshoe (n = 1), and idiopathic (n = 8).
kidney, one of which was associated with bi-
lateral hydronephrosis. Miscellaneous
One patient was found to have papillary ne-
Hydronephrosis and Hydroureter crosis resulting from sickle cell disease
Thirty patients were identified with hy- (Fig. 10). Renal tubular ectasia (Fig. 11) was
dronephrosis; 23 were unilateral and seven identified in four patients.
were bilateral. Fourteen of these 30 patients
had concomitant ureterectasis. Seven cases Pathologic Findings in Other Systems
of ureterectasis without hydronephrosis Other clinically significant findings out-
were found; five were unilateral and two side of the urinary tract included a complex
were bilateral. Causes for hydronephrosis or aortic dissection, extensive deep vein
hydroureter included stones (n = 18), transi- thromboses, a porcelain gallbladder, Crohn’s

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 Split-Bolus MDCT Urography

Discussion
It has been previously shown that CT
urography allows detection of urinary tract
calculi and renal parenchyma and urothelial
lesions in a single, noninvasive examination
[1, 3, 5]. Typical protocols require multiple
image acquisitions to obtain the unen-
hanced, contrast-enhanced nephrographic,
and contrast-enhanced excretory phase im-
ages. The unenhanced images show urinary
tract calculi with very high sensitivity and
specificity [6–9]. Contrast-enhanced images
acquired in the nephrographic phase are use-
ful for identification of lesions within the re-
nal parenchyma. Used in conjunction with
A B unenhanced images, the presence or absence
of enhancement is also useful in distinguish-
Fig. 9—62-year-old woman with microscopic hematuria.
A and B, Coronal maximum-intensity-projection (MIP) image of abdomen (A) and coronal oblique MIP image of ing neoplasms from other processes. Finally,
pelvis (B) from CT urography show complete duplication of right renal collecting system with completely separate contrast-enhanced images in the excretory
upper pole (black arrows) and lower pole (white arrows) ureters all way to level of bladder, both with orthotopic phase are used to evaluate for urothelial le-
bladder insertion. Urologic workup, including cystoscopy, was otherwise completely normal, and cause for
hematuria was not identified. sions. This portion of the examination re-
quires high spatial resolution to detect small
urothelial tumors with high sensitivity. In the
past, the limited longitudinal spatial resolu-
tion of CT compared with excretory urogra-
phy precluded some centers from com-
pletely replacing excretory urography with
CT urography [10]. This problem has been
overcome with the advent of MDCT, which
makes possible rapid acquisition of isotropic
data sets and production of multiplanar re-
constructions with excellent spatial resolu-
tion in the nontransverse plane.
The proliferation of MDCT examinations
has raised concern about radiation exposure.
This is of particular relevance with CT urog-
raphy in which repeated acquisitions may be
performed. The average effective radiation
dose from CT urography has been estimated
to be in the range of 15–35 mSv, with actual
values depending on the specific protocol
used [11, 12]. Other previously reported CT
urography techniques require multiple con-
trast-enhanced acquisitions, resulting in a
minimum of three imaging passes through the
A B abdomen [2–5, 12, 13]. Our technique re-
Fig. 10—23-year-old woman with intermittent gross hematuria for 5 days. duces the total radiation dose by eliminating
A and B, Maximum-intensity-projection (MIP) images from CT urography show pooling of contrast material within one or more imaging passes. By administer-
multiple papillae bilaterally (open arrows) consistent with papillary necrosis. Filling defect within left renal pelvis ing IV contrast material in two boluses sepa-
(solid arrow, B) was shown to represent blood clot at ureteroscopy. Patient was later found to have sickle cell trait.
rated by a suitable time delay, nephrographic
and excretory phases are acquired in a single
imaging pass. With all other scanning param-
disease with fistula formation, and intraduc- toms of lower back pain and pelvic pain, eters held constant, this technique clearly re-
tal papillary mucinous tumor of the pan- respectively. Other important findings in- duces the effective radiation dose when com-
creas (found in two patients). Two patients cluded cholelithiasis (n = 21), diverticulosis pared with MDCT urography protocols using
were identified as having severe degenera- (n = 18), appendicolith (n = 3), ovarian mu- a single contrast bolus.
tive disk disease, which was ultimately de- cinous cystadenoma (n = 1), and ruptured The majority of our patients underwent CT
termined to be responsible for their symp- breast implant (n = 1). urography as part of the workup for hema-

AJR:189, August 2007 319


Fig. 11—Coronal maximum-intensity-projection (MIP)
image from CT urography of 51-year-old woman with
microscopic hematuria and interstitial cystitis.
Medullary pyramids show striated, paint-brush
appearance of renal tubular ectasia.
turia. In many medical centers, a combination
of EU and unenhanced and contrast-enhanced
abdominopelvic CT is used in the assessment
of such patients. The split-bolus protocol re-
quires only two full imaging passes through
the abdomen and pelvis and thus exposes pa-
tients to a similar amount of radiation as a
standard unenhanced and contrast-enhanced
abdominopelvic CT. By eliminating the
additional radiation exposure from EU, the
split-bolus CT urography protocol could the-
oretically result in a radiation dose reduction
compared with a workup performed with a
combination of EU and CT.
Another often-cited issue with MDCT is
the large number of images produced. An
added advantage of the split-bolus protocol is
that fewer images for interpretation are gener-
ated because one acquisition sequence is
eliminated. On the other hand, reducing re-
dundancy in the contrast-enhanced nephro-
graphic and excretory phases may reduce the
likelihood of visualization of the entire col-
lecting system. Segments of the ureter that
may be unopacified or in peristalsis during
the contrast-enhanced acquisition will not
have another chance to be captured during a
second imaging pass. Our CT urography pro-
tocol incorporates the use of digital scout
images obtained immediately after the con-
320
Chow et al.
trast-enhanced abdomen and pelvis phases, to
augment the likelihood of visualizing the en-
tirety of the ureters [14], with only a minimal in-
cremental increase in radiation dose, which is far
less than an additional CT pass would incur.
One of the greatest challenges of MDCT
urography remains obtaining images with
good distention and opacification of the renal
collecting systems and ureters. Proposed tech-
niques for optimizing urinary tract distention
include the use of prone imaging, abdominal
compression, and either IV or oral hydration
[1–5, 13, 15]. Prone imaging has shown little
or no advantage over the other techniques
[2–4]. We have opted to use abdominal com-
pression in all patients for whom compression
is not contraindicated because of its acknowl-
edged benefits when used in conjunction with
conventional EU. Some controversy has arisen
as to the necessity for abdominal compression
with CT urography, with a recent study sug-
gesting that compression does not improve uri-
nary tract visualization [13].
In addition to compression, all patients in
this study were hydrated with oral water be-
fore scanning to aid urinary tract distention
and lower the density of intraluminal con-
trast material. A prospective comparison of
IV versus oral hydration techniques in 40 pa-
tients undergoing compression MDCT urog-
raphy revealed no statistically significant
difference in intraluminal density, streak ar-
tifact from luminal contrast material, or uri-
nary tract distention or opacification [15].
Finally, the scanning delay time for excre-
tory phase imaging must be considered for
optimal urinary tract visualization. Caoili et
al. [13] showed an advantage to excretory
phase imaging at 450 seconds versus 300 sec-
onds. This would support excretory phase im-
aging performed with an effective delay time
of 420 seconds for the kidneys and upper ure-
ters and 450 seconds for the pelvic ureters
with the split-bolus protocol used in this
study. Since this study was conducted, we
have adjusted our technique to 80 mL for the
first bolus and 60 mL for the second bolus,
with an interbolus delay of 6 minutes, with
the objective of improving opacification, but
further investigation is required to determine
the optimal allocation of contrast dose be-
tween the first and second boluses and the op-
timal delay between boluses.
Limited data exist on the sensitivity of
MDCT urography for detecting urothelial le-
sions. In a retrospective review of patients with
surgically proven transitional cell carcinoma of
the upper urinary tract, preoperative MDCT
detected 88% (15/17) of renal collecting sys-
tem tumors and 94% (14/15) of ureteral tumors
[16]. In a series of 106 patients with hematuria,
unexplained hydronephrosis, or both, Cowan
and McCarthy [17] showed MDCT urography
to be superior to retrograde ureteropyelogra-
phy, conventional EU, and sonography in the
detection of urothelial abnormality.
In a retrospective study of 65 patients by
Caoili et al. [5], MDCT urography found 15
of 16 foci of transitional cell carcinoma, with
the one missed lesion occurring at the base of
the bladder. A much lower incidence of
urothelial carcinoma was found in our patient
population, with 24 pathologically proven
cases in a series of 500 patients. In the detec-
tion of upper urinary tract urothelial neo-
plasms, our study showed 100% sensitivity,
confirming the value of this technique for the
detection of upper urinary tract neoplasms.
The marked difference in incidence of urothe-
lial neoplasms between these two studies
most likely results from the difference in pa-
tient populations. Whereas the study by Cao-
ili et al. included only patients at high risk for
urinary tract disease (42 of 65 patients [65%]
with a prior history of urothelial neoplasm),
our study evaluated a screening population,
with only 2.8% (14/500) with a prior history
of urothelial neoplasm.
There were two false-positive studies in
this series for upper urinary tract urothelial tu-
mors. In one case, repeated ureteroscopic bi-
opsy of circumferential urothelial thickening
revealed only inflammatory changes. Inter-
estingly, in the other case, direct visualization
with ureteroscopy also yielded a false-posi-
tive result with visualization of a papillary
ureteral filling defect that was initially de-
tected by MDCT urography and thought to be
neoplastic by both studies. Although these
two cases were considered examples of false-
positive findings for tumor, true morphologic
abnormalities did exist in both.
Our CT urography protocol was 74% sensi-
tive in the detection of bladder tumors. Al-
though CT has been shown to detect bladder
lesions with sensitivities up to 90–95% using
specialized virtual cystography and recon-
struction techniques [18, 19], our protocol was
not similarly optimized for visualizing the
bladder because cystoscopy is routinely per-
formed on patients with hematuria at our insti-
tution. Small tumors at the ureteral orifices
were missed, possibly due to the normal pro-
trusion that is often seen in that region. Mixing
artifacts within the bladder can also result in
false-positive and false-negative interpreta-
AJR:189, August 2007

tions. Despite the improvements in CT spatial
resolution, the use of an anatomic imaging ap-
proach will not provide the ability to identify
the presence of flat bladder tumors such as car-
cinoma in situ. Conventional cystoscopy still
remains the gold standard for evaluation of the
bladder urothelium, and patients with hema-
turia should ideally undergo both CT urogra-
phy and conventional cystoscopy.
The split-bolus protocol also accurately de-
tected all instances of renal cell carcinoma,
suggesting that synchronous acquisition of
nephrographic and excretory phases does not
compromise the ability to visualize the renal
parenchyma. One caution regarding this imag-
ing protocol is that early phase contrast-en-
hanced images, such as during the arterial or
corticomedullary phase, are not obtained.
Thus, this protocol may be suboptimal for the
accurate staging of tumors once they are de-
tected, and such patients may require an addi-
tional study for staging. Given the low inci-
dence of malignancy in our series, however, we
believe that the benefit of reduced radiation
dose to most patients who had no malignancy
outweighs the inconvenience of possible reim-
aging to the few patients with malignancy.
We have found that it remains imperative
that the axial source images are viewed and
interpreted and that appropriate tailored
window and level settings be used when
evaluating the collecting system and ureters
so that dense intraluminal contrast material
does not obscure fine urothelial detail and,
potentially, small urothelial lesions. In addi-
tion to axial images, certain simple recon-
structions can be of great benefit. In particu-
lar, simple sliding thin-slab (3 mm) and
thick-slab (35–50 mm) MIP or average-pro-
jection images of each kidney in a double-
oblique plane to the patient but truly coronal
to the kidney in question provide the most
intuitive display of the data.
Although the MIP algorithm emphasizes
the densely enhanced collecting system, the
nature of the MIP algorithm may result in ob-
scuration of lesions lower in attenuation than
surrounding high-attenuation structures. This
is particularly true for small lesions such as
small urothelial tumors and is exacerbated by
the increasing thickness of the MIP slab.
Thus, one must be cautioned to not interpret
the MIP images, particularly the thick-slab
MIPs, in isolation. Despite this limitation, the
utility of these images lies in the ability to
quickly convey overall anatomic features in
an intuitive fashion. Thus, the images are use-
ful for communicating information to busy
AJR:189, August 2007
Split-Bolus MDCT Urography
clinicians who may not be inclined to scroll
through all of the axial source images.
Our referring clinicians and urologists have
found these images to be most helpful in clari-
fying anatomic relationships in the setting of
renal masses and visualizing the extent of dif-
fuse renal processes such as medullary nephro-
calcinosis, acute or chronic pyelonephritis,
papillary necrosis, or renal tubular ectasia.
Such images may be particularly helpful to the
urologist who is planning nephron-sparing sur-
gery. These images can also be helpful in the
detection of small or subtle lesions. In our se-
ries, one tiny (3 mm) renal pelvic transitional
cell carcinoma was initially missed on the axial
images but detected on the coronal oblique re-
constructed thin-section images.
Although this study includes the largest pa-
tient series for CT urography reported in the
literature at the time of writing, the low inci-
dence of urothelial tumors limits our ability to
assess the effectiveness of this technique in de-
tecting urothelial neoplasms. A larger multi-
center study will likely be necessary to fully
evaluate CT urography for this capacity. Fur-
thermore, this study did not directly compare
the split-bolus protocol with other CT urogra-
phy protocols or with EU. Another weakness
of this study was that primary interpretations of
the CT urography studies were reviewed and a
blinded reinterpretation of the studies was not
performed. Finally, not all patients received
confirmatory studies and, indeed, often the CT
urography results were used to guide subse-
quent evaluation. The relatively long average
clinical follow-up duration (468 days) for pa-
tients with negative CT urography results
should help to mitigate the lack of a pathologic
gold standard in many cases; however, sensi-
tivity and specificity calculations should be
used with caution in light of this bias.
In summary, we have shown that a split-bo-
lus protocol for CT urography can be used suc-
cessfully to evaluate for urinary tract calculi,
renal abnormalities, and urothelial lesions in
one simple, noninvasive examination. Al-
though this study did not include a direct com-
parison between this technique and other
MCDT urography protocols, our data suggest
that the sensitivities and specificities in detect-
ing a variety of abnormalities are comparable
to other protocols. Perhaps more important, the
strong negative predictive values provided by
this CT urography protocol suggest that a uri-
nary tract malignancy is highly unlikely in the
setting of a negative CT urogram.
The split-bolus protocol reduces radiation
dose to patients and results in a smaller num-
ber of images for interpretation compared
with other MDCT urography protocols.
When compared with hybrid CT and EU
strategies for the evaluation of hematuria,
split-bolus CT urography provides equivalent
if not superior visualization of the upper uri-
nary tracts, reduced radiation exposure, and
added logistic convenience. Given the signif-
icant advantages of this protocol, we believe
that it has potential as an alternative to exist-
ing MDCT urography protocols and EU for
the evaluation of the urinary tract.
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322 AJR:189, August 2007