CTU has been shown to be sensitive in detecting upper
tract urothelial cancers. In one series of 57 patients with
hematuria, 38 were found to have urothelial carcinoma. CT urography detected 37/38 urothelial cancers for a sensitivity of 97%, compared with retrograde pyelogram, which detected 31/38 lesions and had a sensitivity of 82%. Approximately 90% of malignant upper tract lesions can be detected with CT urography (McCarthy and Cowan, 2002; Lang et al, 2003; Caoili et al, 2005). CT urography is not as sensitive as cystoscopy for the detection of urothelial tumors in the bladder. Only large bladder tumors are visualized with CT imaging studies as filling defect in the lumen of the bladder. Carcinoma in situ cannot be visualized on CT scanning and therefore cystoscopy is still an important part of a comprehensive MAGNETIC RESONANCE IMAGING CT imaging remains the mainstay of urologic cross-sectional body imaging; however, MRI is increasingly being applied to the genitourinary system. With constant improvements in technology, MRI is gradually narrowing the overall resolution quality gap between it and CT. A significant advantage of MRI is the excellent contrast resolution of soft tissue, without the need for contrast in Key Points: CT Imaging l The CT urogram is an excellent imaging choice to evaluate the kidney, upper tract collecting system, and ureter. l The CT urogram is highly sensitive and specific for upper tract urothelial carcinoma. l A renal mass in the kidney seen on CT urogram that enhances more than 15 to 20 HU is most likely a renal cancer. l With the exception of indinavir stones, all types of urolithiasis are visible on unenhanced CT of the abdomen and pelvis. many situations. Currently MRI is used when patients cannot be given iodinated contrast and when tissue findings in the urinary system cannot be resolved using CT or ultrasonography. To obtain magnetic resonance images, the patient is placed on a gantry that passes through the bore of the magnet. When exposed to a magnet field of sufficient strength, the free water protons in the patient orient themselves along the magnetic field’s z-axis. This is the head-to-toe axis, straight through the bore of the magnet. A radiofrequency (RF) antenna or “coil” is placed over the body part to be imaged. It is the coil that transmits the RF pulses through the patient. When the RF pulse stops, protons then slowly aspirate the fluid instilled. This maneuver should clear any obstruction of the catheter side hole by lubricant or other material. If the catheter is in the bladder, fluid should be aspirated without resistance. If the catheter is still within the urethra, the negative pressure produced during aspiration will cause collapse of the urethral wall and will not permit the return of the instilled fluid. Only when the position of the catheter has been verified should the retaining balloon be inflated, with the amount of fluid indicated on the catheter. Most catheters do safely permit twice the indicated amount of fluid without risk of balloon rupture. Sterile water is the preferred solution for balloon inflation. Air is compressible and might leak, and electrolyte or glucose-based solutions can precipitate and occlude the tubing and valve mechanism. The catheter should be attached to a sterile closed bag system as soon as urine is draining. The drainage bag should be placed below the level of the bladder to encourage one-way gravity flow with the tubing as straight as possible and avoiding kinks that might impair drainage. It has been shown that even the retention of 50 mL of urine in catheterized patients has been associated with an increase in UTIs in up to one third of the patients (Garcia et al, 2007). The temporal exception to this is in patients with acute urinary retention with significant bladder distension in which rapid bladder drainage might precipitate decompression-induced hematuria or “ex vacuo hematuria.” In these patients the catheter should be intermittently clamped and released to permit gradual bladder decompression over 30 to 60 minutes. If the patient is uncircumcised, at this point return the foreskin to its normal reduced position to avoid paraphimosis. Secure the catheter to the patient, allowing for a normal range of motion and without tension, using adhesive tape or a commercial securing device. Female Patients Anatomic Considerations The female urethra is approximately 3.5 to 4 cm long. The meatus is usually in an anterior location and the bladder neck in a posterior location in the horizontal plane, giving the urethra a slight posterior inclination. After antiseptic preparation and sterile draping, use the nondominant hand to spread the patient’s labia (now considered contaminated) to reveal the urethral meatus. After lubrication, insert the tip of the catheter and gently advance using a slightly downward direction, until about half the length of the catheter has been inserted. Check for urine return and activate the anchoring mechanism if used. Difficulties during female catheterization may be encountered for several reasons including the inability to locate the urethral meatus due to obesity and age-related changes and less frequently to strictures (postsurgery, radiotherapy, neoplastic causes). In the obese patient, the use of one or more assistants to provide labial retraction or the use of stirrups can be helpful. In the case of postmenopausal vaginal atrophy or other conditions resulting in the urethral meatus receding into the introitus, we suggest the following alternatives. Holding the index and middle fingers of the nondominant hand together, slowly slide posterior along the introitus until the urethral meatus is palpated and then proceed to slide the fingers just distal to the inferior margin of the meatus. Using the dominant hand, pass the catheter along the groove made by the fingers (this serves a dual purpose—it creates a posterior border with the fingertips and provides a guide for the catheter). As the catheter tip crosses the meatus, it can be felt with the fingertips, thus ensuring proper placement. A second maneuver is to use a vaginal speculum to aid in the retraction and fixation of the introitus. Finally use a coudé tip catheter angled upward and gently slide the tip along the anterior vaginal wall in the midline, until it enters the meatus, and then advance into the bladder. Special Considerations in Children Whenever possible the procedure should be explained in clear and age-appropriate language to the child. Catheterization in children is most commonly performed for drainage, performance of voiding cystourethrogram, or obtaining urine for culture. When attempting to obtain a urine sample for cultures, the use of a portable bladder ultrasound is recommended to ensure that an adequate amount of urine is present in the bladder, thus minimizing the risk of unproductive catheterization (Robson et al, 2006). In female children the correct identification of the urethral meatus is essential to avoid unnecessary catheter contact with the sensitive introitus, leading to discomfort and possibly loss of cooperation by the child. The meatus is just above the superior margin of the introitus and frequently hidden by the superior portion of the hymen. Gentle downward pressure on the upper aspect of the hymen with a cotton ball may allow visualization of the meatus. Failing this maneuver, the catheter tip should be inserted just above the hymen in the midline. In uncircumcised boys, retract the foreskin only until the meatus is visible. In infants and children younger than 3 years of age, when the normal foreskin adhesions have not yet involuted, simply align the preputial opening with the meatus to assist catheter insertion. Difficult Catheterization Difficulty inserting a catheter into the bladder is most commonly due to prostatic growth, urethral stricture(s), bladder neck contracture, or false passage from previous urethral instrumentation. Rarely it is the result of phimosis or urethral calculi. Although these difficulties occur mostly in men, the techniques described herein may be applied to place a catheter regardless of gender (Fig. 7–3). If there is no clinical history of previous sexually transmitted infections (STIs), catheterization, trauma, urethral surgery, or radiotherapy in an adult male over 40 years of age, the most likely cause is prostatic enlargement. Using adequate urethral lubrication and a 16- or 18-Fr coudé tip silicone catheter is often successful in this scenario. If multiple previously unsuccessful attempts have been made and urethral trauma is suspected due to the appearance of a bloody urethral discharge, a false passage or a stricture is likely. A single atraumatic attempt can be made using a 12-Fr silicon/straight or coudé tip catheter. If this maneuver is unsuccessful, then depending on the availability of equipment and the level of experience of the clinician, several other options can be considered. The authors’ preference is to use a flexible cystoscope, allowing a direct visual approach that can be both diagnostic and therapeutic and minimizes the risk of further urethral injury. Under direct vision, the area where the false passage was created or the site of stricture formation is identified and an