URORADIOLGY IMAGING GUIDELINES AND PROTOCOLS
IVU is a time consuming examination and a percentage ofprocedures result in a technicallysub-optimal examination. Each procedure requires an X-ray room for up to 2hours. It would be advantageous to replace the IVP with aCTKUB or CT UROGRAM.
The departmentwill still perform an IVU in complex cases as requested by a Radiologist or Urologist.
It is the responsibility of the referring clinician to check the serum creatinine level prior to requesting any contrast media investigation in high risk patients and patients above the age of 60 years.
CTKUB (STONE PROTOCOL)
Plain spiral low MAS scans will be performed without oral contrast preparation or intravenous contrast. All patients with a scan showing a ureteric calculus which has a Hounsfield unit of greater than 200 HU should have a KUB if there has not been one during the last 24 hours.
This procedure can demonstrate renal tract stones, obstruction of the renal tract and has the advantage that it may demonstrate incidental findings outside the renal tract.
The indication for this examination isAcute or sub acute renal colicwhich may be investigated during normal working hours by CTKUB.
Suspected acute renal colic in A&E may be investigated by urgent CTKUB before 11.00 pm and weekends when the scanner and staff are available.
CT UROGRAM (ONE PHASE)
INDICATIONS
The aim of this examination is to replace the routine IVU examinations. The indications are:-
1.Staging or as a follow up investigation of the upper tract in patients with a known TCC bladder.
2.As a second line investigation for Frank Haematuria or persistent microscopic haematuria>40years(the patient will have had KUB, US and flexible Cystoscopy).
3.Unexplained hydronephrosis.
PREPARATION
A recent serum creatinine level should be available (responsibility of the referring doctor).
Any contraindications for injection of contrast media shouldhave been excluded by the CT radiographer.
PROTOCOL
The patient receives one litre of water to drink prior to scan.
Inject 5-10mg Furosemide (0.1mg per Kg/BW) intravenouslythen Inject 100cc.
Non ionic contrast 300. Wait 7-10 minutes.
The patient is scanned in a supine position from the top of the kidneys to the symphysies pubis.
The images are reformatted in the coronal and sagittal planes.
CT UROGRAM (TWO PHASE)
INDICATION
More complex urological problems. For example:-
1.Non-specific filling defects in renal tract
2.Indeterminaterenal Masses.
3.Trauma.
4.Planning for PCNL.
PREPARATION
Same as one stage Urogram. (See above)
PROTOCOL
The patient receives one litre of water to drink prior to scan.
Plain spiral scans of the abdomen and pelvis.
Inject 5-10mg (0.1mg per Kg/BW) Furosemide i.v. by handfollowed by 100cc Non Ionic contrast 300.
Wait 7 minutes.
Inject 50 cc Non Ionic contrast 300 i.v. by pump injection.
After a delay of 90 second (Porto venous phase) scan the upper abdomen and pelvis.
The images are reformatted in the coronal and sagittal planes.
INTRAVENOUS UROGRAM
WHEN CT IS NOTAVAILABLE OR CT ISNOT PRACTICAL OR IN SPECIAL CASES
IVU for RENAL COLIC
1-PLAIN FILM, if a KUB has not been performed within 24 hours.
(The full length film to include renal area and 2cms below
symphysies)
Inject 50 cc Non Ionic contrast 300 i.v.
2-Full length film in 10 minutes.
3- 20 minutes post micturation full length film
A- IFNORMAL EXCRETION - END OF EXAMINATION
B- IF ABNORMAL EXCRETION
Then delayed films every 1-2 hours until thelevel of obstruction is demonstrated. (Seek advice of Radiologist)
IVU for HAEMATURIA
1-PLAIN FILM, if no KUB has been performed in the last 24 hours
(The renal areas must be included)
Inject Non Ionic contrast 300 i.v, one cc per KG body weight (50 cc for small adults and 100cc for large adults)
2-At 7 minutes perform a full length film to include renal areas.
Apply abdominal compression immediately. (Remove compression if there is obstruction. Seek advice).
3-Perform 3 TOMOGRAMS of the renal areas.
4- Perform a 20 minute full length film (concentrate on renal area).
5- Perform a full length post micturiation film (concentrate on lower
ureters & bladder)
INVESTIGATION OF HAEMATURIA
All patients >40 years old with haematuria should be referred to the one stop haematuria clinics. As part of the clinic investigations patients will normally receive:-
1- Ultrasound renal tract,
2- KUB, and
3- Flexible cystoscopy.
MICROSCOPIC HAEMATURIA
If normal……………follow up by GP
If abnormal……..….investigate
MACROSCOPIC HAEMATURIA
If normal………………..CT-UROGRAM (one phase)
If abnormal……….…….investigate or treat accordingly.
STAGING of BLADDER CANCER UPPER TRACT TCC
Patient requires urgent CT CHEST, ABDOMEN & PELVIS (RCR August 2006). This may show:-
1-Evidence of additional pathology.
2-Local invasion of the tumour.
3-Metastases
Complex cases may require MRI after discussion at MDT.
MRI is superior to CT in demonstrating muscle wall invasion.
INVESTIGATION OF RENAL MASSES
Initial investigation is with ultrasound.
Staging
Arterial phase CT chest & upper abdomen including the kidneys.
Also a Porto-venous phase CT of the abdomen & pelvis.
INVESTIGATION OF THE SCROTUM
Ultrasound is the investigation of choice for all testicular problems.
CT chest and abdomen is required for staging testicular cancers following diagnosis.
Follow up:
a- 3 monthly chest x-rays
b- Yearly CT chest and abdomen
INVESTIGATION OF PROSTATIC CANCER
Initial investigation with PSA. The diagnosis is made with a TRUS & BIOPSY
Not all patients require formal staging. Those that do require:
X-ray
Ultrasound renal tract
Isotope bone scan
MRI abdomen & pelvis
PROTOCOL FOR TRANSRECAL BIOPSY OF PROSTATE
INDICATION
High relative PSAlevel for age of the patient.
Or abnormal digital examination
Or sclerotic bone metastases
OrRising PSA after radiotherapy
PREPARATION
1-The examination technique and the risks and complications are explained by the referring urology team.
2-Information leaflet is sent to the patient.
3-Antibiotic prophylaxis is given for three days, commencing the day prior to the procedure.
Ciprofloxacin twice a day
Metronidazole three times a day
REFERRAL
Only from urology team.
PROCEDURE
1-The radiologist shouldexplain the procedure again, check identity and obtain consent form (form 3).
2- Patient is scanned in the left lateral position, the prostate is scanned and measurements recorded.
3-10cc of 1% local anaesthesia infiltrated around the capsule.
4- Biopsy is performed using a G18 automatic gun. One apical (marked1), one lateral (marked 2), one basal (marked 3) and one transitional zone (marked 4) from each side. The samples are put in separate baskets before putting these into formalin pots. In patients above age 70 years or PSA above 20 all samples from each side are put in to one basket.
5-In those patients who are having a repeat TRUS biopsy 14 biopsies are performed. Two biopsiesfrom eachapical, lateral and basal position. One biopsy from the transitional zone.Send in separate baskets as above.
Appendix I
Intravenous Injection of Furosemide for the purpose of CT Urogram.
Criteria.
- A signed request card should have been vetted by a Radiologist/Radiographer.
- Patients must be 16 years old or over to be classed as adults.
- The dose required for patients under 16 years must be done on a weight basis.
- If the Radiographer is not happy to inject Furosemide a Radiologist must be consulted.
Protocol For Injection
1. A Radiologist must be available in the department
An intravenous injection shall not be commenced by the radiographer until they are sure that the Radiologist responsible for the patient requiring the injection is in the department
2.There shall be another member of staff in the vicinity during the injection to alert the Radiologist if necessary.
3.Following Trust infection control guidelines Ccheck the equipment on the I.V. trolley is correct.
4.Introduce yourself to the patient
- tell them who you are
- check the patients’ identity
- explain the procedure and why the injection is needed
- check whether the patient is diabetic
- check whether any female patients of reproductive age are pregnant or breastfeeding (see Appendix II).
- if any of the above are present consult a radiologist before proceeding.
5.Ask for verbal consent.
6.Wash and dry handsStrict hand hygiene must be observed throughout intervention.
7.Draw up dose required (see protocol), check vials with another member of staff, batch no. and expiry date.
8.All patients must be cannulated If the cannula was already sited or remains in situ beyond the end of the examination record the administration in the patient’s notes.
A radiologist must be summoned if there are two failed attempts at securing venous access.
9.Inject slowly over 20 seconds.
10.Ask the patient if there is any discomfort whilst injecting.
11.Stop injecting if there is any extravasation of Frusemide or any local reaction. Record any extravasation
- If Respiratory arrest occurs
USE DEPARTMENT PROTOCOL TO GET URGENT
ASSISTANCE AND CALL CRASH TEAM 2 2 2 2
13.All reactions however minor must be recorded on the request card.
14.The following should be recorded on the request card:
- Amount of Furosemide administered
- Batch no.
- Expiry date
- Date
- Signature of person administering
P. MURPHY
02.01.2004
Approved by Drugs and Therapeutic Committee
for Radiology
DATE......
LEAD CLINICIAN......
Amended for the purpose of CT Urography by JL Barrow on 7.2.2007
APPENDIX II
Authorised Personnel:
Stoke MandevilleWycombeHospital
Christine McLleodAlison Reid
Joanna RotherhamAmelie Manacap
Deborah KingMarie Macato
Lisa DethickMarilyn Collins
Lynsey KitchSue Moore
Karen OlliffeMoira Greenhow
Emma HoltJudith Burns
Andrew Wainwright.Kirsteen McDougall-Hutchins
Clare McLoughlinPaul Murphy
Robina HeginbothamLinda Hannah
Laura Slimm.Helen RiddellSteve Everard
APPENDIX III
Medicine:Furosemide 20mg/2ml
Injection:10mg/ml 2ml ampuleampoule
Available from:Phoenix, Antigen & Celltech, Martindale
Method of Administration:Intravenous
Dosage:See protocol above
Cautions:Avoid in pregnancy and breastfeeding
Aggravates diabetes mellitus and gout
Enlarged prostate - may cause urinary retention
Contra-indications:Precomatose states associated with liver cirrhosis
Renal failure with anuria
Side effects:Hyponatraemia – low sodium levels
Hypokalaemia – low potassium levels
Hypomagnesaemia – low magnesium levels
Hypochloraemic alkalosis
Hypotension
Increased calcium excretion
Occasionally nausea and gastro-intestinal disturbances
Ototoxicity – leading to tinitustinnitus and loss of balance
Interactions:Taken form BNF website (
Those interactions listed havelisted have potentially hazardous interactions.
Pharmaceutical Group / Pharmaceuticals / ReactionAnti Arrhythmia / Amiodarone, Disopyramide
Flecainide, Quinidine, Mexiletine / Cardiac toxicity, increased if hypokalaemia occurs with loop diuretics
Anti Histamine / Terfenadine / risk of ventricular arrhythmia
Anti Bacterial / Vancomycin / risk of ototoxicity
Anti pyschotics / Pimozide, Sertindole, Thiorazadine / Hypokalaemia, risk of ventricular arrhythmia
Alpha blockers / Prazosin / Enhanced hypotensive effects
ACE Inhibitors / Captopril, Lisinopril / Enhanced hypotensive effects (can be extreme)
Cardiac glycosides / Digoxin / toxicity if hypokalaemia occurs
Beta blockers / Solatol / Risk of ventricular arrhythmia with Solatol by hypokalaemia
Lithium / lithium excretion ( plasma-lithium & risk of toxicity
Reference: British National Formulary at