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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

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