Establishing a standard protocol for the voiding cystourethrography

The voiding cystourethrogram (VCUG) is a frequently performed test to diagnose a variety of urologic conditions, such as vesicoureteral reflux (VUR). The test results determine whether continued observation or an interventional procedure is indicated. VCUGs are ordered by many specialists and primary care providers, including pediatricians, family practitioners, nephrologists, hospitalists, emergency room physicians, and urologists. Current protocols for performing and interpreting a VCUG are based on the International Reflux Study in 1985. However, more recent information provided by many national and international institutions suggests a need to refine those recommendations. The lead author of the 1985 study, R.L. Lebowitz, agreed to and participated in the current protocol. In addition, a recent survey directed to the chairpersons of pediatric radiology of 65 children's hospitals throughout the United States and Canada showed that VCUG protocols vary substantially. Recent guidelines from the American Academy of Pediatrics (AAP) recommend a VCUG for children between 2 and 24 months of age with urinary tract infections but did not specify how this test should be performed. To improve patient safety and to standardize the data obtained when a VCUG is performed, the AAP Section on Radiology and the AAP Section on Urology initiated the current VCUG protocol to create a consensus on how to perform this test.

Establishing a Standard Protocol for the Voiding Cystourethrography

The voiding cystourethrogram (VCUG) is a frequently performed test to diagnose a variety of urologic conditions, such as vesicoureteral reflux. The test results determine whether continued observation or an interventional procedure is indicated. VCUGs are ordered by many specialists and primary care providers, including pediatricians, family practitioners, nephrologists, hospitalists, emergency department physicians, and urologists. Current protocols for performing and interpreting a VCUG are based on the International Reflux Study in 1985. However, more recent information provided by many national and international institutions suggests a need to refine those recommendations. The lead author of the 1985 study, R.L. Lebowitz, agreed to and participated in the current protocol. In addition, a recent survey directed to the chairpersons of pediatric radiology of 65 children's hospitals throughout the United States and Canada showed that VCUG protocols vary substantially. Recent guidelines from the American Academy of Pediatrics (AAP) recommend a VCUG for children between 2 and 24 months of age with urinary tract infections but did not specify how this test should be performed. To improve patient safety and to standardize the data obtained when a VCUG is performed, the AAP Section on Radiology and the AAP Section on Urology initiated the current VCUG protocol to create a consensus on how to perform this test.

Patient entrance surface dose measurements using XR-QA2 Gafchromic films during micturating cystourethrography procedures

The aim of this study was to test the feasibility of using Gafchromic XR-QA2 films in the measurements of patient entrance surface dose (ESD) during the micturating cystourethrogram (MCUG) examination in paediatric patients. Radiochromic films were used to map the entrance dose and to identify the location of peak surface dose (PSD). Direct in vivo measurements of entrance dose were conducted by placing a radiochromic film between the patient and the examination table. The measured ESD values for the commonly performed MCUG fluoroscopic examinations at the authors' institution was in the range of 1.2-7.8 mGy and the PSD in the range of 1.2-8.5 mGy per MCUG procedure for patients with age ranging from 1 to 12 y old. Gafchromic films (XR-QA2) were found to be an efficient and practical dosimetry method that can be easily used to measure clinical patient entrance doses during fluoroscopically guided procedures and potentially in other diagnostic investigations.

Verification of radiation dose calculations during paediatric cystourethrography examinations using MCNP5 and PCXMC 2.0 Monte Carlo codes

The estimation of the radiological risk in the case of children is of particular importance due to their enhanced radiosensitivity when compared with that of adult patients. The purpose of this study is to estimate the organ and effective doses of paediatric patients undergoing micturating cystourethrography examinations. Since direct measurements of the dose in each organ are very difficult, dose-area products of 90 patients undergoing cystourethrography examinations were recorded and used with two Monte Carlo codes, MCNP5 and PCXMC2.0, to assess the organ doses in these procedures. The organs receiving the highest radiation doses were the urinary bladder (ranging from 1.9 mSv in the newborn to 4.7 mSv in a 5-y old patient) and the large intestines (ranging from 1.5 mSv in the newborn to 3.1 mSv in the 5-y old patient). For all ages the main contributors to the total organ or effective doses are the fluoroscopy projections compared with the radiographs. There was a reasonable agreement between the dose estimates provided by PCXMC v2.0 and MCNP5 for most of the organs considered in this study. In special cases, there were systematic disagreements in organ doses such as in the skeleton, gonads and oesophagus due to the anatomical differences between patient anatomic models employed by the two codes.

Imaging the urinary tract in children with urinary tract infection

AIM

To evaluate whether ultrasonography (US) alone is sufficient in imaging the urinary tract in 1185 children with urinary tract infection (UTI).

METHODS

The reports on US and voiding cystourethrography (VCUG) were reviewed.

RESULTS

Initial US was normal in 861/1185 patients (73%). VCUG revealed abnormal findings in 285/861 (33%), of which grade III-V vesicoureteral reflux (VUR) comprised 97 cases (11%). During follow-up, VUR had resolved in 88/97 (91%) patients: in 50/57 (88%) patients without active treatment for VUR, in 27/29 (93%) with endoscopic and in 11/11 (100%) with open surgery for VUR. During follow-up, 11/97 patients (11%) had developed new renal scarring detectable in US, but no renal impairment occurred. Except for VUR, VCUG showed nonobstructive urethral valves in two infant boys with normal initial US. Thus, in 861 children with normal initial US, 40 patients with grade III-V VUR and two patients with significant nonreflux pathology may have benefited from surgical treatment, giving the total number of possibly missed pathological finding in 42/861 (4.9%) cases if VCUG had not been performed.

CONCLUSION

We suggest that children with UTI could be examined using US alone and to use VCUG only after additional indications.

Comparative analysis and interobserver variation of unenhanced computed tomography and intravenous urography in the diagnosis of acute flank pain

OBJECTIVES

The purpose of this study was to compare unenhanced computed tomography (UECT) to intravenous urography (IVU) for detecting urinary tract calculi, signs of obstruction and non-renal causes in the assessment of acute flank pain, and in their interobserver agreement.

PATIENTS AND METHODS

In this prospective study, carried out at a university hospital over a period of 1 year, 36 patients (27 males and 9 females) participated. Mean age was 44 +/- 15 years (range: 14-73 years). The patients presented with acute flank pain and underwent UECT and IVU. The images were blindly evaluated by 2 experienced radiologists and the two techniques compared using the two-tailed McNemar's test for matched pairs; p values <0.05 were considered significant.

RESULTS

UECT detected stones in 11 (30.6%) patients, while IVU found them in only 8 (22.2%). The increased detection by UECT was due to its ability to detect smaller stones (<6 mm). UECT was also found to be better than IVU in determining calculus position, in detecting primary or secondary signs of obstruction and in identifying non-urinary causes of flank pain. The overall average of agreement, as indicated by kappa values, was 0.88 for UECT and 0.61 for IVU.

CONCLUSION

UECT showed better detectability and interobserver agreement tan IVU, suggesting that UECT could replace IVU as the first imaging modality in the evaluation of acute renal colic.

Radiologic evaluation of hematuria: guidelines from the American College of Radiology's appropriateness criteria

Hematuria, symptomatic and incidental, that involves more than three red blood cells per high-power field on two of three properly collected urinalysis specimens warrants some type of imaging to evaluate the upper tracts. Traditionally, excretory urography or the intravenous pyelogram has been the mainstay of the hematuria work-up, but computed tomography urography has more recently been recognized to have significant advantages. Multidetector computed tomography urography, a cross-sectional technique, is less susceptible to overlying bowel gas and more sensitive for detection of small tumors and calculi. Moreover, intravenous-pyelogram-like images can be obtained by using reconstruction techniques. In specific cases, ultrasound examination and magnetic resonance imaging can also be useful, and are particularly helpful in children and pregnant women. Neither modality has the sensitivity of computed tomography for calculi, but small tumors may be visible on magnetic resonance imaging. This article reviews the appropriateness criteria for the various radiologic imaging tests used in the evaluation of hematuria, as proposed by the American College of Radiology.

Radiation dose measurement and risk estimation for paediatric patients undergoing micturating cystourethrography

Micturating cystourethrography (MCU) is considered to be the gold-standard method used to detect and grade vesicoureteric reflux (VUR) and show urethral and bladder abnormalities. It accounts for 30-50% of all fluoroscopic examinations in children. Therefore, it is crucial to define and optimize the radiation dose received by a child during MCU examination, taking into account that children have a higher risk of developing radiation-induced cancer than adults. This study aims to quantify and evaluate, by means of thermoluminescence dosimetry (TLD), the radiation dose to the newborn and paediatric populations undergoing MCU using fluoroscopic imaging. Evaluation of entrance surface dose (ESD), organ and surface dose to specific radiosensitive organs was carried out. Furthermore, the surface dose to the co-patient, i.e. individuals helping in the support, care and comfort of the children during the examination, was evaluated in order to estimate the level of risk. 52 patients with mean age of 0.36 years who had undergone MCU using digital fluoroscopy were studied. ESD, surface doses to thyroid, testes/ovaries and co-patients were measured with TLDs. MCU with digital equipment and fluoroscopy-captured image technique can reduce the radiation dose by approximately 50% while still obtaining the necessary diagnostic information. Radiographic exposures were made in cases of the presence of reflux or of the difficulty in evaluating a finding. The radiation surface doses to the thyroid and testes are relatively low, whereas the radiation dose to the co-patient is negligible. The risks associated with MCU for patients and co-patients are negligible. The results of this study provide baseline data to establish reference dose levels for MCU examination in very young patients.

Antegrade Pyelography Versus Unenhanced Multidetector CT in the Assessment of Urinary-Tract Stones after Percutaneous Nephrostomy Insertion: A Prospective Blinded Study

BACKGROUND AND PURPOSE

In patients with a percutaneous nephrostomy tube (PCN) inserted for symptomatic stone disease, antegrade pyelography is an accepted modality to assess the collecting system and residual stone status prior to PCN removal. Recently, unenhanced multidetector CT (UMDCT) has shown its superiority for the assessment of urinary-tract stones. Comparison of UMDCT with antegrade pyelography has never been done; hence, our aim was to compare the two methods for the assessment of urinary stones in patients with a PCN.

PATIENTS AND METHODS

Between July 2004 and July 2005, we prospectively imaged 49 consecutive patients with known urinary-tract stone disease who had PCN (27 men and 22 women; average age 57 +/- 20 years; range 4-88 years). All patients underwent UMDCT and antegrade pyelography within 24 hours. Both examinations were prospectively and blindly evaluated by two attending radiologists for the presence, location, and size of urinary-tract stones.

RESULTS

According to the findings of both imaging modalities, 18 patients were stone free, and 31 patients had urinary stones. In 20 of the latter 31 patients (64.5%), the urinary stones were diagnosed only by UMDCT. Antegrade pyelography missed renal as well as ureteral stones, with a significant mean size (5.1 x 6.2 mm, and 6 x 5.3 mm, respectively). Antegrade pyelography missed radiolucent (8/20) as well as radiopaque (12/20) stones. In 11 of the 31 patients (35.5%), urinary stones were diagnosed by both UMDCT and antegrade pyelography. The average size of these renal stones was 6 x 11 mm, and the mean ureteral stone size was 11 x 13 mm. In 64% (7/11), the stones were radiolucent and in 36% (4/11) radiopaque. There was no patient in whom urinary stones were diagnosed by antegrade pyelography but missed by UMDCT.

CONCLUSIONS

Unenhanced multidetector CT is more accurate than antegrade pyelography via a PCN for the assessment of urinary-tract stones, with the advantage of reducing the risks of contrast injection side effects.

[Urinary tract injuries in polytraumatized patients]

BACKGROUND

Within the S3 Guideline Project of the European Association of Urology (EAU) an expert committee was set up to develop guidelines for the appropriate management of genitourinary trauma. These European guidelines were accepted in principle as national guidelines by the German Urological Society. Therefore, they also became the basis of the contribution of the German Urological Society to the S3 Guideline Project "Polytrauma" of the German Society for Trauma Surgery.

METHOD

For the guideline "management of genitourinary trauma" all the requirements for classification as S3 guidelines were full-filled. The guideline itself was developed in accordance with the principles of "evidence-based medicine". A systematic analysis of literature published between 1966 and 2004 was carried out. The articles retrieved were assessed in respect of study design and clinical relevance and classified following the scheme of the Centre for Evidence-Based Medicine in Oxford.

CONCLUSION

In suspected renal injuries the hemodynamic situation of the patient is the benchmark for the diagnostic and therapeutic algorithm. The diagnostic gold standard for the assessment of haemodynamically stable patients is CT scanning. Uncontrolled haemodynamic instability is an indication for immediate explorative laparotomy. Partial ureteral tears are managed by stenting; complete tears by immediate surgical repair. Pelvic fractures are often associated with bladder ruptures. Extraperitoneal bladder ruptures, identified by retrograde cystography, are in most cases safely managed by simple catheter drainage. Intraperitoneal ruptures require surgical intervention. Blood at the meatus may suggest a urethral lesion-blind urethral catheterization should not be attempted. Suprapubic cystostomy and delayed urethroplasty are recommended.

Accuracy of reporting of intravenous urograms: a comparison of radiographers with radiology specialist registrars

AIM

To evaluate whether uroradiographers trained to do so can interpret intravenous urograms as accurately as radiology specialist registrars (SpRs).

METHODS

A total of 150 consecutive IVU examinations were prospectively assessed. The preliminary reporter (a uroradiographer, or an SpR in years 1 to 4) wrote a provisional report on each, and all the IVUs were subsequently assessed by an experienced uroradiologist blinded to the provisional report. The uroradiologist's report was taken as the standard. Comparisons between the provisional reports and the standard were made by Pearson chi-squared test (chi(2)).

RESULTS

Data were available for 149 IVUs. In comparison with the standard report, 1st year SpRs interpreted the IVU series with an accuracy of 76%; the combined group of 2nd, 3rd and 4th year SpRs achieved an accuracy of 88%, whereas the uroradiographers demonstrated an accuracy of 92%. Overall, the difference was to be statistically significant (p=0.021), with a linear trend for increased accuracy with increased experience being highly significant (p=0.006).

CONCLUSION

The uroradiographers significantly outperformed all the SpRs from years 1 to 4, achieving 92% accuracy in interpretation compared with an experienced consultant uroradiologist.

Intravenous Urography in Evaluation of Asymptomatic Microscopic Hematuria

BACKGROUND AND PURPOSE

In 2001, the American Urologic Association Best Practice Policy Panel recommended CT or intravenous urography (IVU) over ultrasonography as the initial imaging modality in patients with asymptomatic microhematuria. We here present results of a study initiated many years ago and completed prior to 2001 that provides information pertinent to the use of IVU as the initial imaging modality for such patients.

PATIENTS AND METHODS

This study compared the results of IVU and ultrasonography in patients 40+ years of age who were referred to a single urology department for evaluation of microscopic hematuria between 1994 and 2000. There were 290 patients who agreed to participate by undergoing ultrasonography in addition to IVU; 247 completed both tests. There were 81 men and 166 women with a mean age of 56.4 years (range 40-86 years). Thirty patients (12%) were smokers.

RESULTS

A renal lesion or mass suggestive of tumor was found in 8 patients (3.2%); 3 patients had this finding on the IVU examination and 5 on ultrasonography. None of the patients had such a lesion/mass on both examinations. Two patients with suspect lesions were ultimately found to have renal-cell carcinoma. Both of the patients with renal cancer had a suspect lesion on the ultrasound examination but not on the contemporaneous IVU.

CONCLUSION

Intravenous urography may miss lesions/masses that lead to a diagnosis of upper-tract neoplasia.

Application of renal Doppler sonography in the diagnosis of obstructive uropathy in patients with spinal cord injury

OBJECTIVES

To assess renal resistive index (RI) changes in patients with spinal cord injury (SCI) who have obstructive uropathy and to determine if an RI of 0.7 or more is useful in identifying such patients.

DESIGN

Prospective cross-sectional study.

SETTING

Rehabilitation hospital affiliated with a medical university.

PARTICIPANTS

A convenience sample of 99 kidneys of 51 SCI patients (38 men, 13 women; mean age, 38.8+/-14.0 y) with neuropathic bladder dysfunction.

INTERVENTIONS

Ultrasonic examination to assess the degree of hydronephrosis, Doppler sonography to calculate renal vascular RIs, and radioisotopic renography to assess renal function and to determine excretory curves. Kidneys were assigned to control or obstructive uropathy groups, and RIs were compared for statistical significance (Student t test) and to assess whether an RI of 0.7 is a distinguishing criterion.

MAIN OUTCOME MEASURES

RI and sensitivity.

RESULTS

Average RIs were .58+/-.07 in the control group (71 kidneys) and .65+/-.08 in the uropathy group (28 kidneys) (P<.001). The sensitivity of using an RI of 0.7 or more to identify patients with obstructive uropathy was 39%. The c statistic of the receiver operating characteristic curve was .72.

CONCLUSIONS

RIs increased in SCI patients with obstructive uropathy. In patients with SCI, urinary findings fit the chronic partial obstruction pattern. A renal RI of 0.7 or more was a poor indicator of obstructive uropathy in such patients.

Intravenous urography-virtual cystoscopy is a better preliminary examination than air virtual cystoscopy

OBJECTIVE

To describe a new technique of virtual cystoscopy (VC, used previously but with catheterization to drain residual urine and insufflation with air or carbon dioxide) with no invasive catheterization, used in parallel with intravenous urography (IVU), as conventional cystoscopy is an invasive but essential examination, and VC with multislice computed tomography (CT) was introduced to make preliminary examinations noninvasive.

PATIENTS AND METHODS

Using multislice CT and a device with 16 rows of detectors, we examined five patients using VC that previously involved catheterization, termed 'air VC' and 16 using VC with the new technique, termed 'IVU VC'. We assessed the new technique by evaluating the tumour detection rate, and merits and demerits of both types of VC.

RESULTS

The detection rate of bladder tumours by IVU VC was similar to that from air VC; moreover, IVU VC overcame two significant disadvantages of air VC, i.e. the appearance of the water surface and the need for catheterization.

CONCLUSION

Conventional cystoscopy is still an essential examination but this new method of IVU VC may be ideal for preliminary examination of the bladder.

[Abdominal polyarteritis nodosa: angiographic features]

PURPOSE

Polyarteritis nodosa (PAN) is a systemic vasculitis of small and medium size arteries. The purpose of this study is to evaluate imaging findings, especially angiographic features, of 17 patients with abdominal involvement from polyarteritis nodosa.

PATIENTS AND METHODS

We reviewed the medical records and imaging findings of 17 patients with PAN involving the abdomen. All patients underwent digital subtraction angiography of the renal or visceral arteries completed by a post-angiographic KUB. Abdominal CT scan was available in three patients. All patients underwent muscle biopsy. A surgical biopsy of the gallbladder was obtained in one patient.

RESULTS

Multiple small aneurysms involving small and medium sized arteries were detected at angiography in 12 patients. CT showed a renal subcapsular hematoma in two patients and acute pancreatitis in one patient.

CONCLUSION

Involvement of gastrointestinal and renal arteries is frequent in polyarteritis nodosa. The diagnosis of PAN should be considered when multiple small-sized aneurysms are present at angiography even if biopsy is negative.

Multidetector CT urography in imaging of the urinary tract in patients with hematuria

This review article comprehensively discusses multidetector CT urography protocols and their role in imaging of the urinary tract in patients with hematuria.

[Value of perineal sonography for diagnosing anterior urethral stenosis]

OBJECTIVES

To determine the value of perineal sonography in the diagnosis of urethral stenosis and evaluation of surrounding fibrosis. Materials and methods. Fifty-eight healthy subjects underwent urethral sonography. Thirty-two patients with suspected urethral stenosis underwent sonography after retrograde distension of the urethra using normal saline and retrograde urethrogram and voiding cystourethrogram.

RESULTS

The mean diameters of the healthy urethra varied from 11 to 15 mm. The mean thickness of normal periurethral tIssue was between 2 and 4mm. Sonography detected 34 stenoses (97.4%). The length of the stenosis was significantly longer at sonography compared to retrograde urethrogram and voiding cystourethrogram. No significant difference was found between both techniques when measuring urethral diameter. In all cases, the thickness of periurethral tIssues was greater at the stenotic level than at a normal level, irrespective of the involved segment. There was no correlation between the thickness of periurethral tIssues and the degree of stenosis.

CONCLUSION

Urethral sonography is a method that permits diagnosis of urethral stenosis and evaluation of periurethral fibrosis. It may replace retrograde urethrogram and voiding cystourethrogram in the diagnosis of post infectious stenosis.

Radiation doses to paediatric patients up to 5 years of age undergoing micturating cystourethrography examinations and its dependence on patient age: a Monte Carlo study

The effective dose received by children up to 5 years of age from micturating cystourethrography (MCU) examinations was estimated in this study. The MCU examination consisted of 5 radiological views, 2 anteroposterior (AP) and three oblique (OBL) views. Entrance surface doses (ESD) were measured with thermoluminescent dosimeters for 30 children. The average ESD values per view varied from 0.34 mGy up to 0.57 mGy. In order to calculate the organ and effective doses, Monte Carlo MCNP-4A radiation transport simulation code was used. It was applied to three mathematical phantoms representing newborn, 1 and 5 year old children and all the patients were classified in those three groups. The effective dose conversion factors (C(f)) were calculated as the ratio of effective dose over the entrance dose. The C(f) factors decrease as the children's age increases. Children simulated by a newborn mathematical phantom, had C(f) factors almost double those represented by a 1-year-old mathematical phantom. For children simulated by a 5 year old phantom, the C(f) factors for AP and OBL views were almost the same. This was true for both male and female patients. The mean effective dose per view for male and female patients was found to be E=0.16 mSv. The effective dose per examination for male patients was E=0.86+/-0.31 mSv and E=0.76+/-0.28 mSv for female patients.

Individual patient variation and inter-rater reliability of lower calyceal infundibular width on routine intravenous pyelography

OBJECTIVE

To standardise infundibular width (IFW) measurement, to determine patient variability, and to determine inter-rater variability on intravenous pyelography (IVP).

PATIENTS AND METHODS

Fifty outpatient IVP films were randomly drawn from two hospitals between 1 July 1998 and 31 August 1999, and examined to measure the lower calyceal IFW on the 5, 10 and 20 min films with compression, and after voiding. Kidneys with previous renal surgery, hydronephrosis or renal anatomical anomalies were excluded; in all, 81 kidneys from 50 patients were examined. The IFW was measured at the narrowest point along the infundibulum. All 50 films were then reviewed by two urologists unaware of their origin, to determine the inter-rater reliability of the infundibular measurements.

RESULTS

Analysis of variance (anova) with posthoc analysis showed a significant difference in IFW at each phase of the IVP (repeated measures anova, P < 0.001). The mean (95% confidence interval) IFW was greatest on the compression film, at 4.4 (2.6) mm, and least on the postvoid film, at 1.6 (2.1) mm. Overall inter-rater reliability was 0.9780 (intraclass correlation coefficient), and the Pearson correlation between each rater for the IFW at each phase of the IVP was >/= 0.886.

CONCLUSIONS

There is wide variability in lower calyceal IFW among the various IVP films in a given study. Thus any predictive value of the IFW must be standardized for the timing and IVP film type (compression, postvoid, etc.). The inter-rater reliability of IFW is high, suggesting that if used correctly it may be more useful in predicting the outcome after shock wave lithotripsy.

Evaluation of transurethral cystoscopy and excretory urography for diagnosis of ectopic ureters in female dogs: 25 cases (1992-2000)

OBJECTIVE

To evaluate transurethral cystoscopy and excretory urography for diagnosis of ectopic ureter in female dogs and identify concurrent urogenital abnormalities.

DESIGN

Retrospective study.

ANIMALS

25 female dogs.

PROCEDURE

Medical records of female dogs that underwent transurethral cystoscopy, excretory urography, and ventral cystotomy were reviewed for signalment, history, physical examination findings, results of bacteriologic culture of urine, and surgical findings. Videotapes of transurethral cystoscopy and radiographic studies were reviewed systematically without knowledge of surgical findings.

RESULTS

Ectopic ureters were diagnosed in 24 of 25 (96%) of the dogs, bilaterally in 22 of 24 (91.6%) dogs. Cystoscopic evaluation yielded a correct diagnosis in all dogs when results of ventral cystotomy were used as the diagnostic standard. Cystoscopic evaluation identified a terminal ureteral opening for all ureters. Urethral fenestrations, troughs, striping, and tenting were identified. Abnormalities of the vestibule were identified in all examinations available for review (24/25). The paramesonephric septal remnant and its association with ectopic ureters were identified and characterized by cystoscopy. Radiographic findings were discordant with surgical findings and correctly identified 36 of 46 (78.2%) ectopic ureters and 2 of 4 normal ureters. Hydroureter and renal abnormalities were associated with distal urethral ectopic ureters on radiographic evaluations.

CONCLUSIONS AND CLINICAL RELEVANCE

Transurethral cystoscopy was accurate and minimally invasive for identification and classification of ectopic ureters in dogs. Contrast radiography had limitations in diagnosis of ectopic ureters. Cystoscopic findings and associated vaginal and vestibular abnormalities support abnormal embryologic development in the pathogenesis of ectopic ureters.

Investigation into patient doses for intravenous urography and proposed Irish diagnostic reference levels

With the introduction of Council Directive 97/43/Euratom, all member states should establish relevant diagnostic reference levels for X-ray examinations. Diagnostic reference levels help to facilitate standardisation and optimisation within departments and attempt to reduce dose variations between hospitals. High variation of individual patient doses for plain-film examinations by up to a factor of 75 was demonstrated by a previous Irish study, which highlighted the necessity for further investigation into other examinations in Ireland. The current work aimed to establish reference values for intravenous urography (IVU) examinations, an important contributor to collective dose. Eleven Irish hospitals were randomly selected, representing 30% of the total number of hospitals. Dose-area product (DAP) readings for IVUs were recorded along with technical and procedural details. Resultant data demonstrated mean hospital and individual patient DAP variations of a factor of 4 and 58, respectively. Stepwise regression analysis demonstrated that number of images taken, method of image acquisition and patient weight were the main causal agents for dose variations recorded. A proposed diagnostic reference level of 12 Gy cm(2) was established at the level of the third-quartile value of the mean hospital DAP values. This article provides evidence of large variations in DAP values for IVU examinations. It is hoped that application of the proposed DRL of 12 Gy cm(2 )will reduce the size of these variations.

[Radiography and ultrasonography in the management of bladder tumors: 71 cases at the National Hospital Center of Yalgado Ouedraogo (Burkina Faso)]

The bladder's cancer is frequent in West Africa. Urinary schistosomiasis endemicity helps to explain this high incidence. It is a pathology of late diagnosis, little or badly explored by imaging. Through a retrospective survey of 71 patients' files aged in average of 51.7 years, all having a bladder's tumour which is clinically shown by an haematuria, the major symptom, often by a pelvic volume, and who have all gone through an abdominal echography and/or intravenous urography (IVU) and/or retrograde urethrocystography (UCR), we have tried to point out the role of imaging in the caring of this pathology in our working context. Imaging, with a 98.5% sensibility for sonography and 100% for IVU, took part in all the cases to the diagnosis, to the search of urinary signs of reflux, associated signs authorizing a diagnostic orientation, but was excluded from the evolutive follow-up due to the poverty of our populations. So, despite some limits specific to the survey, particularly the absence of historadiological comparison for all the files, echography and IVU with cystography have always led to malignancy diagnosis. Therefore they should be requested for any patient consulting for haematuria.

Comprehensive ultrasound versus voiding cysturethrography in the diagnosis of vesicoureteral reflux

This study evaluates the accuracy of noninvasive renal ultrasound (US) in the detection of dilative vesicoureteric reflux (VUR) compared to voiding cysturethrography (VCUG), taking both sonographic morphology and kidney length into account. The data and images of 205 paediatric patients who had renal ultrasound and VCUG performed were reviewed. Abnormalities of renal length and kidney morphology were compared with degree of reflux on VCUG for each renal unit. A total of 407 renal units were evaluated. When the sonographic diagnosis of reflux was based solely on morphological criteria and degree of dilatation, correlation with VCUG results was poor. However, the fraction of kidneys of anomalous size increased markedly with grade of reflux, from 10% of non-refluxing renal units to 50% of renal units subjected to grade 4 and 5 VUR. Taking abnormal kidney length into account as well, dilative VUR was diagnosed by ultrasound with a sensitivity of 92% (95% CI 82%-100%) and a sensitivity of 67% (95% CI 63%-72%), P<0.001.

CONCLUSION

the results of this study show that ultrasound cannot accurately diagnose vesicoureteric reflux by morphological changes alone, but requires the consideration of age-adjusted abnormalities in kidney length.

The value of cystoscopy and intravenous urography after magnetic resonance imaging or computed tomography in the staging of cervical carcinoma

The clinical staging system for cervical carcinoma presently recommended by the International Federation of Gynecology and Obstetrics (FIGO) does not include MRI or CT findings and thus suffers limited accuracy. Recently however, the positive contributions of MRI and CT to preoperative staging have been reported. This study involves a determination of the value of routine cystoscopy and intravenous urography, in the detection of bladder invasion or hydronephrosis resulting from cervical carcinoma, among patients who had undergone MRI or CT. Among a total 296 patients with cervical carcinoma, 271 patients (92%) had undergone MRI and 25 (8%) CT. Bladder invasion was identified pathologically by cystoscopic biopsy in 8 (57%) of the 14 patients with suspected bladder invasion on MRI or CT. There was no bladder invasion in any of the other cases lacking in bladder invasion evidence on MRI or CT. Hydronephrosis was identified by intravenous urography in 18 patients, as it also was in all of these cases on MRI or CT, confirming a negative predictive value for MRI or CT, in detecting bladder invasion or hydronephrosis from cervical carcinoma, of 100%. Therefore, although MRI or CT cannot totally replace cystoscopy, the latter is unnecessary in the absence of bladder invasion evidence on MRI or CT. Intravenous urography, however, can be safely omitted whenever MRI or CT is performed.

[Ultrasound for initial evaluation of post-traumatic renal lesions in children]

PURPOSE

To describe the findings and limitations of color doppler ultrasound (CDUS) compared to enhanced CT in the evaluation of pediatric renal trauma and to determine the indications for first line imaging work up.

PATIENTS AND METHODS

17 children (9 girls) aged 3 to 18 years were shown to have one or multiple post-traumatic renal lesions. All renal lesions were unilateral. All children presented with hematuria (microscopic (n=8), gross (n=7), not specified (n=2)). 16 had CDUS and enhanced CT (gold standard). A 13-year old girl had been imaged by both CDUS and IVU.

RESULTS

No correlation between the degree of hematuria and the severity of renal lesion could be found. Final diagnosis was: fracture with uro-hematoma (n=6), contusion (n=5), pedicular lesion (n=2), clotted ureter (n=1), intra cystic hemorrhage (n=1), subcapsular hematoma (n=1), urinoma with no evidence of fracture (n=1), extra-urinary lesion (n=7). In four cases, CDUS was abnormal but the diagnosis of fracture had not been made. In 3 cases, a uro-hematoma was present and CDUS misdiagnosed a pedicular lesion.

CONCLUSION

Imaging strategy should not rely on the type of hematuria. Presence of a urinoma alters the sensitivity of CDUS. When performed in ideal conditions, a comprehensive normal CDUS examination is probably sufficient to exclude a major renal injury.

Unenhanced spiral CT scan in the initial evaluation of renal colic: AUBMC experience

BACKGROUND AND OBJECTIVE

Until recently, intravenous urography and ultrasonography have been the standard diagnostic modalities in the initial evaluation of acute flank pain. However, since 1995 the role of non-enhanced CT scan (NECT) has become more important in establishing the diagnosis of renal colic. In this retrospective descriptive study, we evaluated the usefulness of NECT in the diagnosis and management of patients with suspected urinary tract stones at the American University of Beirut-Medical Center (AUBMC).

MATERIALS AND METHODS

We reviewed the records of 102 patients who presented to AUBMC over a period of two years for flank pain with or without hematuria. NECT were obtained in all patients. We studied the images for the presence of stones and frequency of associated urinary findings. Incidental abdominal and pelvic abnormalities were recorded.

RESULTS

Fifty-four patients were found to have positive CT examinations for the presence of urinary tract stones on the ipsilateral side of the flank pain. Twenty-two stones were present in the kidneys, 23 in the ureters and 16 at the ureterovesical junction (UVJ). In these 54 patients with stone disease, 31 had associated pelvicalyceal dilatation (57%), and 16 had perinephric streaking (29.6%). In the 39 patients with ureteral and UVJ stones, 26 had ureteral dilatation (66.6%), and 17 had periureteral streaking (43.5%). In the 23 patients with only ureteral stones, 10 had a positive rim sign (43.4%).

CONCLUSION

A diagnosis of urinary tract stone is not always readily apparent on the basis of physical exam and laboratory studies. NECT is now universally accepted as a preferred method for the evaluation of ureteral and kidney stones in patients with suspected renal colic.

[Renal onococytic adenoma]

Renal oncocytic adenoma. Renal oncocytic adenoma is a rare neoplasm now considered as a benign tumour. The purpose of this paper is to describe the radiological features of this tumour and to assess the value of imaging work-up in the diagnosis and management of patients with renal oncocytic adenomas.

Radiologic diagnosis and surgical treatment of urethral diverticulum in women. A reappraisal of voiding cystourethrography and positive pressure urethrography

OBJECTIVE

To reappraise the optimum radiologic procedure for the diagnosis of urethral diverticula in women and to assess the results of surgery.

STUDY DESIGN

From January 1994 to December 1997, 132 urine-continent women with pelvic prolapse and the most characteristic symptoms of urethral diverticulum underwent pelvic repair. In addition to routine urologic evaluations and pelvic examinations, the women underwent voiding cystourethrography (VCUG) and positive pressure urethrography (PPUG) with a double-balloon catheter. The x-ray examination was scheduled as follows. One hundred thirty-two women initially underwent VCUG followed by a PPUG. Another VCUG was subsequently performed on women with a negative PPUG finding. Twelve patients were excluded because they were unable to urinate for the first VCUG; thus, the study group was composed of the remaining 120 patients. Subsequently those patients underwent various pelvic operations, including total abdominal/vaginal hysterectomy, abdominal colposacropexy, Manchester's operation, sacrospinous ligament suspension, diverticulectomy and colporrhaphy.

RESULTS

Both VCUG and PPUG were able to demonstrate the diverticula in 20 of the 120 women. Another 13 women showed positive findings on PPUG. Ten of the 87 cases with a negative PPUG had a positive finding in the subsequent VCUG. Forty-two diverticula were detected in 39 patients during pelvic repair. The only complication of urethral diverticulectomy was urethrovaginal fistula, which occurred in 3 of the 39 patients.

CONCLUSION

Though VCUG is not as sensitive as PPUG, it still has merits and can be used as a screening test. If VCUG is inconclusive but clinical suspicion persists, particularly when PPUG is doubtful, magnetic resonance imaging should be considered.

The diagnostic yield of intravenous urography

BACKGROUND

Intravenous urography (IVU) is considered an integral imaging component of the nephro-urological work-up in a wide array of clinical settings. At our institution there is an open-access policy with regard to requesting IVU studies.

METHODS

In a prospective, blinded observational study we undertook to assess the diagnostic yield of IVU with respect to the source of referral (i.e. Urology, Nephrology, GP, A & E, other speciality) and the presenting features, such as renal colic, haematuria, bladder outflow obstruction, recurrent urinary tract infection (UTI) etc. Two hundred consecutive patients were evaluated.

RESULTS

Overall, 23% of tests were positive. There was a highly significant difference in diagnostic yield between the groups (P<0.001 for both referral source and test indication). A positive result was most likely after referral by a kidney specialist (37.1%) and when the test indication was renal colic (42%) or haematuria (32%). The yield was <15% in all other circumstances, with 94.9% and 92.1% of GP- and other hospital speciality-initiated IVUs being negative. When investigating recurrent UTI, 91.7% of tests were negative and 86.2% were negative when the indication was bladder outflow obstruction.

CONCLUSIONS

It is suggested that an open access policy for IVU is not justified, especially when cost and the risk associated with contrast media and radiation exposure are taken into account. Our study supports the abandonment of routine IVU in the investigation of UTI and bladder outflow obstruction.

Sonographic diagnosis of hydronephrosis in patients with spinal cord injury: influence of bladder fullness

OBJECTIVE

To investigate and compare the diagnostic accuracy of prevoid and postvoid renal sonography in detecting hydronephrosis in patients with spinal cord injury.

STUDY DESIGN

A prospective, blind comparison of renal sonography and excretory urography in 67 spinal cord injury patients who underwent periodic urologic examinations. Renal sonography was performed twice, once when the patient's bladder was physiologically full (prevoid) and again when it was just emptied (postvoid).

RESULTS

Of 140 kidneys, 24 from 16 patients were found to have hydronephrosis by excretory urography; 116 kidneys had normal urogram findings. Prevoid sonography missed the diagnosis of hydronephrosis in one kidney and showed hydronephrosis in 18 kidneys that had normal results on excretory urography (sensitivity, 95.8%; specificity, 84.5%; negative predictive value, 99.0%). The postvoid sonograms did not detect hydronephrosis in four kidneys and showed hydronephrosis in six kidneys that had normal results on excretory urography (sensitivity, 83.3%; specificity, 94.8%; negative predictive value, 96.5%). Compared to excretory urography, renal sonography detected eight more upper urinary tract abnormalities, which were confirmed by cystograms or radioisotopic renograms.

CONCLUSION

Performing renal sonography while the bladder is full can increase the sensitivity in detecting hydronephrosis in asymptomatic spinal cord injured patients.

A comparison of a non-ionic dimer, iodixanol with a non-ionic monomer, iohexol in low dose intravenous urography

A prospective, double-blind study of 392 patients randomized into four groups was performed to establish whether diagnostic intravenous urograms could be obtained with a lower dose of iodine when using the dimeric, non-ionic contrast medium iodixanol compared with the monomeric, non-ionic iohexol. Patients received iodixanol or iohexol containing either 9 or 12 g of iodine (gI). The primary parameter was the diagnostic quality of the 6 min film, assessed in a blinded fashion, by consensus, by four radiologists. Iodixanol at both doses was diagnostic in over 90% of cases. Iohexol was only diagnostic in 74% (9 gI) and 81.8% (12 gI). Pairwise comparisons revealed that iodixanol 9 gI was significantly better than both iohexol 9 gI (p = 0.0005) and 12 gI (p = 0.014). No significant difference was present for different doses within the same contrast medium group. Iodixanol resulted in poorer bladder distension than iohexol. Iodixanol caused significantly less discomfort than iohexol.

Optimizing urography

Urography is regarded as one of the best screening tests for evaluation of urinary tract disease and is commonly used in the search for a cause of hematuria or the presence of upper tract urothelial masses. It is also used in the evaluation of patients with trauma, known or suspected urolithiasis, or renal infection and for the documentation of obstruction or congenital abnormalities. The physician should have a basic understanding of iodinated contrast media and their benefits and effects on the patient. Patient risk factors include a history of (1) renal impairment, (2) significant allergies, (3) asthma, (4) diabetes mellitus, and (5) cardiac disease (particularly congestive heart failure, arrhythmias, unstable angina, recent myocardial infarction, and primary pulmonary hypertension). Changing options for imaging modalities, contrast media, and patient preparation require continued attention to detail and individualization to allow optimization of the urographic examination.

The effect of patient positioning on mural filling defects during double contrast cystography

Different radiographic findings may be observed during double contrast cystography due to patient positioning affecting the distribution of positive and negative contrast media. A mass lesion was created in the urinary bladder of a canine cadaver to allow evaluation of the effect of patient positioning on the appearance of a mass during double contrast cystography. The mass appeared as a filling defect only on those views where positive contrast medium surrounded the mass. Otherwise, the mass appeared as a summation. Additionally, a patient is described illustrating the effect of patient positioning on detecting mural filling defects during double contrast cystography.

Ureteral calculi in patients with flank pain: correlation of plain radiography with unenhanced helical CT

PURPOSE

To determine the sensitivity and specificity of plain radiography for the detection of ureteral calculi with use of unenhanced helical computed tomography (CT) as the standard of reference.

MATERIALS AND METHODS

Plain radiographs and helical CT scans of 178 patients with acute flank pain were reviewed retrospectively. Three interpretations of plain radiographs were used: (a) Original reading. This was the report made at the time of the patient's evaluation before the patient underwent CT. (b) Blinded retrospective reading. Each plain radiograph was interpreted without knowledge of the CT findings. (c) Unblinded retrospective reading. The plain radiograph of each patient whose CT scan showed a stone was reviewed with the CT scan.

RESULTS

The original reading had a sensitivity of 45% and a specificity of 77% for the detection of ureteral calculi. The blinded retrospective reading had a sensitivity of 59% and a specificity of 71%. The unblinded retrospective reading had a sensitivity of 59% (95% confidence interval: 47%, 70%).

CONCLUSION

Plain radiography is of limited value for aiding the diagnosis of ureteral stones. All patients with acute flank pain for whom radiologic imaging is recommended can directly undergo unenhanced helical CT; plain radiographs need not be obtained first.

Accuracy of detection and measurement of renal calculi: in vitro comparison of three-dimensional spiral CT, radiography, and nephrotomography

PURPOSE

To compare accuracy of three-dimensional (3D) spiral computed tomography (CT) performed without administration of contrast material with that of radiography and linear nephrotomography in detection and measurement of renal calculi.

MATERIALS AND METHODS

Fifty renal calculi within an abdominal phantom were imaged with 3D spiral CT, radiography, and linear nephrotomography. Spiral CT data were analyzed with workstation-based 3D imaging software, with a thresholding procedure based on the maximally attenuating voxel within each calculus during measurement. Measurement accuracy and detection rates were compared according to modality. Conventional and magnification-corrected measurements from radiography and linear nephrotomography were included.

RESULTS

Spiral CT depicted calculi and allowed determination of the collective two-dimensional and 3D linear measurements statistically significantly more accurately than the other techniques; the mean linear measurement errors along individual axes did not exceed 3.6%. With 3D spiral CT, calculus volumes were determined with a mean error of -4.8%.

CONCLUSION

3D spiral CT enabled highly accurate determination of the volumes and all three linear dimensions of renal calculi. In addition, 3D spiral CT depicted calculi more sensitively than traditional techniques and provided new information and improved accuracy in the evaluation of nephrolithiasis.

Radiologic findings in acute urinary tract obstruction

Acute urinary tract obstruction, a common disease in daily practice, often requires performance of emergency intravenous urography (IVU). However, the spectrum of urographic abnormalities seen with acute obstruction has not been thoroughly addressed. The purpose of this study was to explore the IVU findings in patients with acute urinary tract obstruction. Records of 380 patients who underwent IVU in our hospital during a 6-mo period were reviewed for IVU evidence of acute urinary tract obstruction. Of the 380 patients, 53 (14%; 39 men, 14 women; average age = 43 yr) had acute urinary tract obstruction. All obstructions except one were located in the lower one-third of the ureter. The causes of acute urinary obstruction included ureteral stones in 34 (64%), ureteral edema or lucent stones in 16 (30%), neoplasms in 2 (4%), and inflammatory disease in 1 (2%). Abnormal radiologic findings were hydroureter in 46, nephropyelographic delay in 36, hydronephrosis in 35, interureteric ridge edema in 11, persistent dense nephrogram in 6, urine extravasation in 5, vicarious excretion in 1, striation in 1, and stricture in 1. Radiographic results were normal in one patient. The most common clinical indications of acute ureteral obstruction are flank pain and hematuria, and calculi are the major cause. In one-third of patients, radiopaque calculi are not detectable with IVU during acute urinary tract obstruction. A careful and thorough evaluation of the IVU should be performed in patients with clinical indications of acute urinary obstruction.

Preoperative evaluation of tumor extension in patients with recurrent cervical cancer

BACKGROUND

Pelvic exenteration is an option in the treatment of locally recurrent cervical cancer. Various preoperative diagnostic procedures in the estimation of tumor invasion of the bladder and rectum or lymphonodal involvement were evaluated.

DESIGN

The sensitivity and specificity of cystoscopy, intravenous pyelography, irrigoscopy, rectoscopy, and computed tomography were evaluated by comparing the preoperative findings with the histological result as the 'golden standards'.

RESULTS

In the assessment of bladder invasion the sensitivity of cystoscopy, intravenous pyelography and computed tomography was 22.2%, 55.6% and 55.6%, respectively. The overall sensitivity of the three diagnostic procedures was 77.8%. In the assessment of invasion of the rectum irrigoscopy, rectoscopy and CT revealed a sensitivity of 33.3%, respectively. Only 50% of all cases with tumor infiltration of the rectum showed positive results when all three diagnostic procedures were combined. The sensitivity and specificity of computed tomography in the diagnosis of lymphonodal involvement were 75% and 83.3%, respectively.

CONCLUSION

We think that there is an obvious necessity for all diagnostic procedures for patient selection prior to pelvic exenteration. However, all these investigations are not conclusive but complement each other. Prior to pelvic exenteration, critical interpretation of all preoperative diagnostic procedures is mandatory, otherwise surgery results in an unintended palliative procedure.

Excretory urography before prostatectomy

A study of the pre-operative excretory urograms of 205 patients who had prostatectomy for benign prostatic hyperplasia, over a 5-years period is presented. Seventy-four per cent (74.1%) of the urographic abnormalities were a direct result of prostatic enlargement found on clinical examination. The significant upper tract abnormalities found in 11.0% of the cases were duplex kidneys (3.4%), poor renal excretion (3.8%) and small kidneys (3.8%). None of these was a contraindication to prostatectomy when the blood urea and creatinine levels became normal. No upper tract tumour nor calculus was found in these patients. We conclude that, for the management of patients presenting with urinary retention from BPH, routine pre-operative excretory urography has little or no value and is not worth the expense and delay.

[The diagnostic value of digital and conventional imaging in intravenous urography]

PURPOSE

To compare image quality of digital luminescence radiography with conventional film-screen techniques during excretion urography. Four field tests and ROC analysis for determining diagnostic value.

MATERIAL AND METHOD

135 patients were included in a prospective study. Three independent observers judged the five minute (59 cases) or ten minute (76 cases) films after contrast injection using digital images as well as corresponding conventional images (five minutes-76 cases, ten minutes-59 cases).

RESULTS

The digital technique provided better information concerning the renal parenchyma, the soft tissues and bone structures. Contrast enhanced detail was demonstrated equally well by both systems. The two systems had similar sensitivity but digital radiography showed higher specificity.

Emergency intravenous pyelography in the setting of possible renal colic: is it indicated?

STUDY OBJECTIVE

To determine whether emergency IV pyelography (IVP) adds significant information to clinical judgment in the setting of possible renal colic.

DESIGN

A prospective voluntary survey of a convenience sample of physicians at the time of patient encounter.

SETTING

The emergency department of a university hospital, annual census 50,000 visits.

PARTICIPANTS

Emergency medicine faculty physicians.

INTERVENTION

Physicians were surveyed before and after IVP was performed on patients with possible renal colic.

RESULTS

Over the course of 12 months, 62 patients with possible kidney stones were evaluated by 14 different faculty ED physicians, who filled out surveys. Before IVP results were obtained, 63% of patients were thought to have a high (more than 75%) probability of ureteral obstruction. In 59% of these patients, the IVP results showed ureteral obstruction. The IVP revealed unexpected findings in 42% of all patients, including normal results in 19%, ureteral stones in 5%, higher than expected grade of obstruction in 6%, and lower than expected grade of obstruction in 6%, and lower than expected grade of obstruction in 5%. Management was reported to have been changed in 60% of all patients for a wide variety of reasons, but consideration of alternative diagnosis was the most common reason, occurring in 23%. Management changes included unexpected hospital admission in five patients (9%) and emergency urologic consultation in five patients (9%).

CONCLUSION

Emergency IVPs are useful in the evaluation of patients with suspected renal colic, primarily when they rule out ureteral obstruction and allow consideration of alternative diagnoses. Not uncommonly, emergency urologic consultation or hospitalization occurs on the basis of IVP findings.

Is routine urography necessary in all patients undergoing suprapubic transvesical prostatectomy?

One hundred and forty consecutive patients were offered transvesical prostatectomy after haematological and urinary investigations but without urography. The results of treatment are comparable to those in similar setting where urography had been performed as a routine procedure. While the renal function was generally poor in the earlier period, improving later in the study period, no urinary abnormality which would have affected outcome was missed by clinical assessment and other investigations. In view of the high cost of urography and possible adverse effects we believe that unless specifically indicated by presence of haematuria or loin pain urography is unnecessary in the diagnostic work of patients for transvesical prostatectomy.

Investigative techniques, assessment of incontinence, and urodynamics

The past year's literature reflects a continued interest in studying and refining standard investigative techniques, both urodynamic and radiographic, that have long been used to evaluate patients with lower urinary tract dysfunction. In addition, new, simple, and inexpensive technologies that allow relatively accurate diagnosis and that minimize medical costs have been introduced. These continued efforts to understand the pathophysiology of the lower urinary tract better bring both the practicing physician and the urogynecologist closer to making correct diagnoses and appropriate therapeutic decisions.

A trial to assess the effectiveness of bowel preparation prior to intravenous urography

A randomized prospective trial was undertaken to compare the relative effectiveness of two commonly used bowel preparations (senna tablets and sodium picosulphate powder) administered to patients before they underwent out-patient intravenous urography. Their 'control' films were compared with plain 'kidneys, ureters, and bladder' (KUB) radiographs of patients who had had no bowel preparation. The results show no significant difference in the degree of faecal shadowing between those receiving a bowel preparation and the unprepared patients. Nor is there any difference between the two laxatives. We conclude that the routine administration of a bowel preparation is unlikely to improve the diagnostic quality of out-patient intravenous urograms. In addition, 40% of the urogram patients found the effects of the laxatives to be unpleasant or very unpleasant.