100 living-related kidney donor evaluations using digital subtraction angiography.

Intravenous digital subtraction angiography (IV-DSA) combined with excretory urography was used to evaluate the renal anatomy of 100 potential living-related kidney donors. Each of the 100 patients underwent subsequent nephrectomy to verify the number and distribution of renal vessels. For the entire series, 71 patients had bilateral single, 2 bilateral multiple and 27 multiple renal arteries on one side determined by angiography. Eleven patients required standard catheter angiography due to inadequate IV-DSA studies. Four patients who had a single artery imaged by IV-DSA were found to have an additional vessel at the operation. The overall accuracy of IV-DSA to identify the number of renal vessels was 96% (85/89). The sensitivity of the exam was 100% (94/94) and the specificity was 67% (4/6). It is concluded that IV-DSA combined with excretory urography is a safe, cost effective, and suitable method to image the renal anatomy of potential kidney donors. Thus about 90% of donors can be spared the risks and inconvenience of standard angiography, and the donor evaluation can now be performed on an outpatient basis.

Scintigraphic demonstration of lower extremity periostitis secondary to venous insufficiency.

The scintigraphic findings on bone imaging in two patients with extensive lower extremity periostitis secondary to venous insufficiency are presented. One of these patients had bilateral disease. The use of [67Ga]citrate scanning in an attempt to exclude concurrent osteomyelitis is also addressed.

Controlled endoscopic retrieval of ectopic ureteral catheters using fluoroscopic guidance.

The double-J ureteral catheter has been popularized as an ideal internal ureteral stent. Migration of the distal end of the catheter up the ureter, however, can complicate its safe removal. A safe, controlled method of stent extraction is described using a C-arm fluoroscopic unit.

Correlation of radionuclide and ultrasound studies with biopsy findings for diagnosis of renal transplant rejection.

The diagnosis of early renal transplant rejection is of the utmost importance to the transplant recipient. Unfortunately, such a diagnosis is often extremely difficult to make. In an attempt to clarify this issue we retrospectively evaluated 35 patients with the presenting diagnosis of rejection for the correlation of comparable radionuclide (RN) and ultrasound (US) examinations with biopsy findings. In 21 patients with heavy interstitial mononuclear cell infiltration, 22 of 23 serial RN studies within forty-eight hours of biopsy were positive for rejection. Only 3 of 14 comparable US studies were positive for rejection. When examinations performed within approximately fourteen days were evaluated, 7 of 11 RN studies were positive for rejection, while 2 of 9 comparable US studies were positive for rejection. However, in 14 patients with mild or no interstitial cellular infiltration, only 6 of 13 RN studies were positive, while all 4 US examinations were negative. In the group evaluated at approximately two weeks, 2 of 6 RN studies were positive, while 0 of 5 US studies were positive. We conclude that the serial RN study is more sensitive than US examination for the diagnosis of acute rejection. US, however, proved valuable in the identification of transplant complications (i.e., fluid collections, ascites, and hydronephrosis).

Management of extraperitoneal bladder rupture.

Extraperitoneal bladder ruptures secondary to blunt trauma are caused by fractures of the bony pelvis 95 per cent of the time. A static cystogram is the only way to diagnose the lesion definitely. We have treated our 41 patients successfully with catheter drainage alone despite extensive urinary extravasation. Eighty-seven per cent of the ruptures will be healed in 10 days, and virtually all will be healed in 3 weeks.

Urethrography in the diagnosis of acute urethral injuries.

Urethrography has proved to be tremendously valuable in the evaluation of patients with suspected acute urethral injuries. The authors review the techniques of examination, the anatomy, and the urethrographic classification of acute injuries in the male patient.

Provocative imaging. Diuretic renography.

Diuretic renography remains the noninvasive functional study of choice in patients with hydronephrosis resulting from apparent UPJ obstruction. Meticulous attention to proper patient preparation, radiopharmaceutical selection, furosemide dosage and administration, and image interpretation and an awareness of potential pitfalls are essential for accurate diagnosis. For most patients, the F + 20 protocol is sufficient, however; the F-15 protocol allows clarification in cases of equivocal baseline F + 20 studies. Invasive antegrade techniques such as the Whitaker pressure/perfusion test are best reserved for patients in whom the diagnosis remains equivocal after diuretic renography, or in patients with massive hydronephrosis or renal insufficiency. New standardized protocol guidelines should help to ensure studies that are reproducible in different nuclear medicine laboratories.

Computed tomography of the kidney.

The development and refinement of computed tomography have revolutionized the diagnostic evaluation of patients in urologic practice. This article reviews the applications and interpretation, as well as the limitations, of renal computed tomography and compares this modality with other imaging studies of the kidney.

The indeterminate renal mass.

Ultrasound and CT scan play complimentary roles for the evaluation of indeterminate renal masses. Fast MR imaging with and without gadolinium is performed for characterization of renal masses when patients have a contraindication to iodinated contrast material. Radiologists have a primary role in detecting and managing indeterminate renal masses.

Guided cyst puncture and aspiration.

With the widespread acceptance of ultrasonography and computed tomography for the evaluation of renal masses, the role of guided renal cyst puncture in the evaluation of a suspected renal cyst has undergone revision in recent years. In this article, the authors review the technique, interpretation, and complications of diagnostic cyst puncture and attempt to define its current diagnostic and therapeutic indications.

Radiology of the bladder and urethra in blunt pelvic trauma.

Appropriate radiologic studies are mandatory for assessing the extent and nature of lower urinary tract injuries following blunt pelvic trauma. A flow sheet summarizing these radiographic studies is presented in Figure 24. With pelvic fracture, two injuries may be found--extraperitoneal rupture of the bladder and rupture of the posterior urethra. In some patients, these injuries may be combined. Intraperitoneal rupture of the bladder occurs as a result of a blow to the lower abdomen or pelvis in patients whose urinary bladder is distended at the time of injury. A pelvic fracture may or may not be present. Anterior urethral injuries are more commonly associated with instrumentation in the male patient; they may, however, occur as a result of blunt injury to the external genitalia or perineum.

Computed tomography in blunt trauma.

Until now, CT has been utilized very little in the evaluation of the bluntly traumatized patient. Based on our early experience, we have attempted to demonstrate the CT features of a spectrum of injuries. Much of this information is new and additional studies will have to be performed to elucidate fully the benefits of computed tomography in the diagnosis of trauma. A method of study has been outlined which stresses the use of intravascular, oral, and, when needed, rectal contrast materials for study in these patients.

Percutaneous cholecystostomy and lithotripsy of gallstones.

Extracorporeal lithotripsy has a high incidence of postprocedure biliary colic and slow disappearance of gallstones. This situation has led to the development of a new technique which has been successful in four patients and consists of percutaneous cholecystostomy, direct stone visualization, and fragmentation of gallstones with a percutaneous lithotripter. All patients had a functioning gallbladder, stone diameter less than 30 mm, and abdominal pain secondary to cholelithiasis. The procedure was performed in a two day hospitalization. Initially, under general anesthesia, the gallbladder was intubated with a 21 gauge needle and guidewire and the tract dilated to #30 French. A nephroscope was advanced into the gallbladder through a rigid sheath. All gallstones were visualized, fragmented with a percutaneous lithotripter, and extracted. After a postoperative cholecystocholangiogram, an self-retaining catheter was placed in the gallbladder for an average of 2.5 days. Three of the four patients were discharged from the hospital in two days without any complications. A fourth patient had a small bile leak treated with antibiotics. After an average of 13 months follow-up, all patients had a normal ultrasound or oral cholecystogram and no biliary tract symptoms. This technique is safe and efficient in removing gallstones and has no recurrence of gallstones in the 13 month follow-up period.

Radiology of the urinary system in the emergency department.

Three straightforward radiologic examinations are the cornerstone of the diagnosis of a wide variety of urinary tract pathology that may be encountered in the emergency department. This article reviews some technical aspects of the examinations, the radiologic findings, and some controversial aspects of the diagnosis and subsequent management of these patients.