R e s i d e n t s ’ S e c t i o n • S t r u c t u r e d R ev i ew A r t i c l e
O’Connor et al.
CT Urography
Residents’ Section
Structured Review Article
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Residents
inRadiology
CT Urography
Owen J. O’Connor 1 Key Points
Michael M. Maher 1. Standard CT urography consists of unen-
hanced, nephrographic, and pyelographic
O’Connor OJ, Maher MM phases.
2. CT urography is an excellent technique
for the evaluation of urinary tract calcu-
li and renal masses, having high sensitiv-
ity and specificity for both conditions be-
cause it facilitates multiplanar imaging of
the urinary system.
3. Compression, an IV saline bolus, and di-
uretics have been used to optimize ureter-
ic distention with variable results.
4. Whether CT urography should replace ex-
cretory urography in the evaluation of he-
maturia remains controversial. Definitive
resolution of this question is limited by a
lack of randomized studies.
The European Society of Urogenital Ra-
diology defines CT urography as a diagnos-
tic examination optimized for imaging the
kidneys, ureters, and bladder with thin-slice
MDCT, IV administration of contrast me-
dium, and image acquisition in the excre-
tory phase [1]. CT urography resembles ex-
cretory urography in that the examinations
consist of unenhanced, nephrographic, and
Keywords: CT urography, hematuria pyelographic phases [2]. CT urographic pro-
DOI:10.2214/AJR.10.4198
tocols are being refined, and efforts are be-
ing focused on optimization of radiation ex-
Received December 30, 2009; accepted after revision posure and urothelial imaging. This review
February 2, 2010. describes the current status of CT urography
1 as a standalone imaging study in the evalua-
Both authors: Department of Radiology, University
College Cork and Cork University Hospital, Wilton, tion of hematuria.
Cork, Ireland. Address correspondence to M. M. Maher
(m.maher@ucc.ie). Imaging Technique
Radiologists have used the imaging tech-
WEB
This is a Web exclusive article.
niques of excretory urography to develop
CT urographic protocols. A typical CT uro-
AJR 2010; 195:W320–W324 graphic protocol has three phases that allow
complete evaluation for the most common
0361–803X/10/1955–W320
urologic causes of hematuria, that is, calcu-
© American Roentgen Ray Society li, renal masses, and urothelial tumors (Fig.
1). After an initial unenhanced acquisition,
W320 AJR:195, November 2010
nephrographic phase images are acquired
90–100 seconds after administration of a
nonionic contrast agent (100–150 mL of 300
mg I/mL at 2–4 mL/s) [3]. Imaging (2.5- to
5-mm slice thickness) is typically confined
to the kidneys during this phase. Nephro-
graphic phase imaging has the highest sen-
sitivity in the detection of renal masses, and
correlation with unenhanced images is re-
quired to show unequivocal enhancement.
Pyelographic phase images are acquired
5–15 minutes after contrast administration
to evaluate the urothelium from the kidneys
to the bladder (Fig. 2).
Imaging Features
Skeptics argue that unlike excretory urog-
raphy, CT does not yield physiologic informa-
tion based on the degree of delayed excretion,
which is considered an index of the severity
of obstruction on excretory urograms [2]. CT
urography, however, does reliably show signs
of obstruction, including hydronephrosis, hy-
droureter, ipsilateral renal enlargement, peri-
nephric and periureteric fat stranding, peri-
nephric fluid, and ureterovesical edema [3, 4]
(Fig. 3). The combination of hydronephrosis,
hydroureter, and perinephric stranding has a
positive predictive value of 90% for obstruc-
tion in the presence of urinary tract calculi
[3]. The soft-tissue rim sign is a circumferen-
tial rim of soft-tissue attenuation surrounding
abdominal or pelvic calcification. This sign is
a reliable indicator that the calcification lies
in the ureter and thus aids in differentiation of
distal ureteric calculus from pelvic phlebolith
[5]. CT urographic findings also help predict
the likelihood of stone passage in that larger
stones are less likely to pass spontaneously.
Spontaneous passage rates for ureteric calcu-
li are 76% for calculi 2–4 mm in diameter,
60% for calculi measuring 5–7 mm, 48% for
those measuring 7–9 mm, and less than 25%
for stones larger than 9 mm [6].

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B
Fig. 1—36-year-old man with right renal colic due
to distal ureteric calculus. Imaging of pelvis was
performed with patient prone to ascertain whether
stone was in distal ureter or in bladder. Because of its
size (< 3 mm), stone should pass spontaneously.
A, Unenhanced pelvic CT urogram shows calculus
(arrow) in region of vesicoureteric junction on right.
B, Sagittal reconstruction of unenhanced CT
urogram confirms that calculus (arrowhead) is not in
dependent portion of bladder and is therefore in distal
ureter, not in bladder.
Malignant urologic tumors, such as renal
cell carcinoma and transitional cell carci-
noma, are potentially detectable during un-
enhanced imaging examinations. Renal cell
carcinoma and transitional cell carcinoma
typically appear solid on unenhanced images
and have higher attenuation (5–30 HU) than
urine [7]. Possible malignant tumors are fur-
ther characterized with contrast-enhanced
CT urography. Malignant renal and urothe-
lial tumors both exhibit early enhancement
and washout after IV contrast administration,
which assists in characterization [8]. Because
of this property, an enhancing urothelial le-
sion can be detected in the nephrographic
phase, in which urine has low attenuation
(Fig. 4). Greater than 10 HU lesion enhance-
ment compared with the findings on unen-
Fig. 4—68 year-old man with transitional cell
carcinoma of bladder and congenital absence of left
kidney. Heterogeneous lymph node mass is present
on right side.
A, CT scan through pelvis shows soft-tissue mass
(arrowhead) in bladder that contrasts with low-
attenuation urine in bladder.
B, Nephrographic phase CT urogram shows soft-
tissue mass (arrow) to left of midline near dome of
bladder and absence of left kidney.
AJR:195, November 2010 W321
CT Urography
Fig. 2—52-year-old man with renal cysts. Coronal
reformation of pyelographic phase CT urogram shows
multiple bilateral parapelvic renal cysts (arrows).
hanced images indicates the lesion is solid.
Greater than 20 HU enhancement strongly
suggests the lesion is malignant [9] (Fig. 5).
CT urography accurately depicts the lo-
cation of lesions. Renal cell carcinoma orig-
inates in the renal cortex between the corti-
comedullary junction and the renal periphery
(Fig. 6). Transitional cell carcinoma of the
kidney is generally seen as a sessile filling de-
fect on pyelographic phase images and may
compress and displace the renal sinus fat [7].
Although advanced transitional cell carcino-
ma infiltrates the renal parenchyma causing
A B
Fig. 3—45-year-old man
with obstructing calculus
in distal part of left ureter.
Coronal reformation of
unenhanced CT scan
shows hydronephrosis
and hydroureter on left.
Calculus (arrowhead) is
in distal ureter. Extensive
streak artifact from left
total hip replacement is
evident.
architectural distortion, the reniform shape is
usually maintained, whereas it is not in renal
cell carcinoma [7]. Infiltration can cause focal
delay of enhancement, but this finding is non-
specific [7]. Foci of necrosis make it difficult
to differentiate transitional cell carcinoma
from lymphoma, metastatic lesions, and xan-
thogranulomatous pyelonephritis. Enhance-
ment of ureteric transitional cell carcinoma
at the site of ureteric obstruction is best seen
in the nephrographic phase and facilitates dif-
ferentiation from ureteric calculi. Additional
features of transitional cell carcinoma of the
ureter include wall thickening, stenosis, and
infiltration of the fat, which manifests peri-
ureteric fat stranding (Fig. 7).
 O’Connor et al.
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A B
Fig. 5—74-year-old woman with left-sided renal cell carcinoma.
A, Unenhanced CT scan shows solid left renal lesion (arrow) and expansion of renal contour.
B, Nephrographic phase CT scan shows avid peripheral enhancement with central hypoattenuation
(arrowhead) suggesting necrosis. Fig. 6—57-year-old man with renal cell carcinoma.
Coronal CT scan shows tumor (arrow) originating
in corticomedullary region of kidney and distorting
Advantages of CT Urography firm conclusions about the diagnostic accu- normal contour of kidney. Findings strongly suggest
Three-dimensional reformations with cor- racy of imaging studies in determining the presence of renal cell carcinoma.
onal and sagittal maximum intensity projec- cause of hematuria.
tions of the kidneys and urinary collecting differences in the attenuation of calculi and
systems facilitate thorough examination for Techniques Used to Overcome the surrounding soft tissues.
renal and urothelial malignancy. The advan- Limitations of CT Urography Radiation doses in CT urography can be
tages of unenhanced CT over excretory urog- Many variations of the standard CT uro- reduced by limiting the number of imaging
raphy in the detection of urinary tract calcu- graphic protocol have been investigated with phases through the use of dual-energy CT or
li are well established. Reports have shown the goal of reducing radiation exposure and split-bolus technique [3, 13]. Dual-energy CT
sensitivity ranging from 98% to 100% and optimizing imaging of the urothelium. Cao- obviates an unenhanced phase of imaging be-
specificity of 92–100% for unenhanced CT ili et al. [12] reported radiation doses of 25– cause virtual unenhanced CT scans can be
in the detection of urinary tract calculi [4]. 35 mSv for four-phase CT urography com- postprocessed from a contrast-enhanced study
Unlike excretory urography, CT for the eval- pared with a mean effective dose of 3.6 mSv acquired with two tube potentials operating
uation of urinary tract calculi (stone proto- for excretory urography. Radiation doses can simultaneously [13]. This CT technique has
col) does not require IV contrast adminis- be reduced for the unenhanced component of shown great promise for differentiating solid
tration in most circumstances, and the risk CT urography because image noise, which renal masses from hyperdense renal cysts and
of nephrotoxicity associated with excretory increases with radiation dose reduction, is for determining the composition of renal cal-
urography is therefore eliminated. less likely to be a problem because of marked culi, which may help guide treatment.
It is widely accepted that CT urography
outperforms ultrasound, excretory urog-
raphy, and radiography in the evaluation
of renal parenchymal masses and urinary
tract calculi. Study results [10] suggest that
CT urography has excellent sensitivity (89–
100%) and specificity in the detection of pel-
vicaliceal and ureteric transitional cell car-
cinoma. Data have prompted investigators
in the field to conclude that CT urography
is more sensitive and specific than excretory
urography in the detection of urothelial tu-
mors. It has been suggested [1] that CT urog-
raphy be performed as a first-line technique
in the evaluation of hematuria when the risk
of disease outweighs the risk of radiation
exposure, as in the care of patients at high
A B
risk of urologic cancer. The debate contin-
ues, however. A 2006 systematic review [11] Fig. 7—59-year-old man with transitional cell carcinoma of ureter.
of diagnostic tests and algorithms used for A, Coronal reformation of unenhanced CT urogram shows soft-tissue thickening (arrow) of left mid ureter,
proximal hydroureter, and hydronephrosis of small atrophic kidney.
investigating hematuria concluded that the B, Axial pyelographic phase CT image shows increased soft-tissue thickening and expansion of left ureter with
available evidence was insufficient to draw stranding of periureteric fat (arrowhead). Right ureter (arrow) is normal.

W322 AJR:195, November 2010

 CT Urography

Radiation doses can be reduced with use
of a split-bolus (two-phase) technique in
which an unenhanced acquisition is followed
by IV administration of 30–50 mL of con-
trast material, and a second bolus of 80–100
mL of IV contrast material is given after an
8- to 10-minute delay, during which the ac-
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der (pyelographic phase) are assessed in a re-
duced the number of phases at a reduced ra-
diation dose. A possible disadvantage of the
split-bolus technique is that the presence of
contrast material within the ureter at imag-
ing can obscure the subtle isoattenuating tu-
mors that are not seen in the low-dose unen-

quisition is performed [3] (Fig. 8). Thus in a hanced phase (Fig. 9).
single nephropyelographic phase acquisition, Detection of urothelial tumors is wide-
the renal parenchyma (nephrographic phase) ly believed to rely on optimal distention and
and the collecting system, ureters, and blad- opacification of the ureters and pelvicaliceal

Fig. 8—45-year-old man with normal findings. CT
urogram obtained with split-bolus technique shows
collecting systems opacified by administration
of small volume of IV contrast material before
acquisition in nephrographic phase, which included
second injection of IV contrast material.
Fig. 9—61-year-old man with hematuria due to transitional cell carcinoma of bladder with ureteric extension.
A, Ultrasound image shows asymmetric thickening (arrow) of wall of bladder.
B, Excretory urogram shows large filling defect (arrowhead) in bladder that may be explained by blood clot.
C, Unenhanced CT scan shows focal thickening (arrow) of bladder wall.
D, CT scan shows extension of soft tissue from bladder into distal ureter (arrowhead) at vesicoureteric junction.
E, Pyelographic phase CT scan shows tumor (arrow) is not apparent owing to presence of contrast material in
bladder.
F, Three-dimensional reformation confirms presence of tumor (arrowhead) in distal ureter and shows ipsilateral
hydronephrosis. 

A B C

D E F

AJR:195, November 2010 W323


system. Complete bilateral distention of the
ureters can be difficult to achieve owing to
peristaltic contractions [9]. Oral hydration
with 1 L of water 20–60 minutes before CT
urography can improve delineation of the
ureters by promoting diuresis [14]. Water has
the additional benefit of serving as a negative
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contrast agent in the gastrointestinal tract. It
has been suggested [15] that prone imaging
improves ureteric distention and opacifica-
tion, but the prone position can be uncom-
fortable, and the benefits of prone imaging
are disputed. Imaging in the prone position
is used, however, to discriminate free intra-
vesical stones and those impacted at the ure-
terovesical junction. Compression, saline
infusion, and diuretics also have been in-
vestigated for optimizing ureteric imaging.
Compression can increase proximal ureteric
distention and can be released for imaging of
the distal ureters. Compression techniques,
however, require additional imaging and in-
crease radiation exposure. Even with com-
pression, 25% of ureteric segments are not
visualized, which is not significantly differ-
ent from the results with CT urography with-
out compression [16].
The benefits of saline infusion are debated
because studies have yielded conflicting re-
sults [12, 15]. Authors have suggested that sa-
line infusion occasionally stimulates peristal-
sis, which can have a deleterious effect on CT
urography [15]. Because of these limitations,
the European Society of Urogenital Radiology
[1] does not advocate routine use of saline in-
fusion. In a review, Silverman et al. [9], how-
ever, conclude that despite the potential lim-
itations, saline infusion is safe, inexpensive,
and easy to incorporate into the CT urograph-
ic protocol. Administration of a low dose of
diuretic (furosemide 0.1 mg/kg to a maximum
of 10 mg) 1 minute before CT urography im-
proves mid and distal ureteric opacification
and distention compared with that achieved
with saline infusion alone [9]. This technique
decreases attenuation in the ureters and re-
duces the time delay for pyelographic imag-
ing but is not suitable for all patients [1].
A disadvantage of CT urography com-
pared with excretory urography is encoun-
tered in imaging of patients with asymmetric
excretion, particularly those with unilateral
obstruction. In these patients, the lack of se-
quential imaging with CT urography can re-
sult in suboptimal opacification in the pyelo-
graphic phase on the obstructed side. Many
experts agree that regardless of the CT uro-
graphic protocol used, there will always
W324 AJR:195, November 2010
O’Connor et al.
be ureteric segments that are suboptimally
opacified and distended [5]. There are con-
cerns that urothelial lesions in unopacified
segments might be missed because of these
deficiencies [2]. This view, however, is not
universally held; some investigators have
found that urothelial neoplasms almost al-
ways manifest filling defects or obstruction
[10]. Tsili et al. [10] found that the finding
of a nonopacified ureter had a negative pre-
dictive value of 100% for the presence of
urothelial lesions.
Conclusion
MDCT is the most sensitive and specific
test for the diagnosis of urinary tract calcu-
li and for detecting and characterizing renal
masses [2]. The universal acceptance of CT
urography as a one-stop imaging examination
in the investigation of hematuria is prevented
by the scarcity of evidence (lack of random-
ized controlled studies and meta-analyses) to
support a view that CT urography is as accu-
rate as excretory urography in the evaluation
of urothelium. In addition, results of eco-
nomic analyses suggest that it may be cost-
effective to use ultrasound to evaluate persis-
tent hematuria and to perform CT urography
only if the ultrasound results are normal [11].
Many radiologists believe that the addition-
al radiation exposure in CT urography has re-
placed concerns regarding sensitivity in the
detection of urothelial tumors as the major ob-
stacle to replacing excretory urography with
CT urography. The American College of Ra-
diology [17] considers CT urography highly
recommended for the investigation of hema-
turia. Split-bolus and low-dose imaging tech-
niques are potentially effective methods of ra-
diation dose reduction that may strengthen the
argument for the use of CT urography in place
of excretory urography.
References
1. Van der Molen AJ, Cowan NC, Mueller-Lisse UG,
Nolte-Emsting CC, Takahashi S, Cohan RH; CT
Urography Working Group of the European Soci-
ety of Urogenital Radiology (ESUR). CT urogra-
phy: definition, indications and techniques—a
guideline for clinical practice. Eur Radiol 2008;
18:4–17
2. Nolte-Ernsting C, Cowan N. Understanding mul-
tislice CT urography techniques: many roads lead
to Rome. Eur Radiol 2006; 16:2670–2686
3. O’Connor OJ, McSweeney SE, Maher MM. Im-
aging of hematuria. Radiol Clin N Am 2008;
46:113–132
4. Fielding JR, Silverman SG, Rubin GD. Helical CT
of the urinary tract. AJR 1999; 172:1199–1206
5. Kawashima A, Sandler CM, Boridy IC, Takahashi
N, Benson GS, Goldman SM. Unenhanced helical
CT of ureterolithiasis: value of the tissue rim sign.
AJR 1997; 168:997–1000
6. Coll DM, Varanelli MJ, Smith RC. Relationship
of spontaneous passage of ureteral calculi to stone
size and location as revealed by unenhanced heli-
cal CT. AJR 2002; 178:101–103
7. Browne RF, Meehan CP, Colville J, Power R, Tor-
reggiani WC. Transitional cell carcinoma of the
upper urinary tract: spectrum of imaging find-
ings. RadioGraphics 2005; 25:1609–1627
8. Lang EK, Macchia RJ, Thomas R, et al. Improved
detection of renal pathologic features on multi-
phasic helical CT compared with IVU in patients
presenting with microscopic hematuria. Urology
2003; 61:528–532
9. Silverman SG, Leyendecker JR, Amis ES Jr.
What is the current role of CT urography and MR
urography in the evaluation of the urinary tract?
Radiology 2009; 250:309–323
10. Tsili AC, Efremidis SC, Kalef-Ezra J, et al. Multi-
detector row CT urography on a 16-row CT scan-
ner in the evaluation of urothelial tumors. Eur
Radiol 2007; 17:1046–1054
11. Rodgers M, Nixon J, Hempel S, et al. Diagnostic
tests and algorithms used in the investigation of
hematuria: systematic reviews and economic
evaluation. Health Technol Assess 2006; 10:10,
iii–iv, xi–259
12. Caoili EM, Inampudi P, Cohan RH, Ellis JH. Op-
timization of multi-detector row CT urography:
effect of compression, saline administration, and
prolongation of acquisition delay. Radiology
2005; 235:116–123
13. Graser A, Johnson TR, Chandarana H, Macari M.
Dual energy CT: preliminary observations and
potential clinical applications in the abdomen.
Eur Radiol 2009; 19:13–23
14. Kawamoto S, Horton KM, Fishman EK. Opacifi-
cation of the collecting system and ureters on ex-
cretory-phase CT using oral water as contrast
medium. AJR 2006; 186:136–140
15. Sanyal R, Deshmukh A, Sheorain V, Taori KC.
Urography: a comparison of strategies of upper
urinary tract opacification. Eur Radiol 2006;
17:1262–1266
16. Sudakoff GS, Dunn DP, Hellman RS, et al. Opaci-
fication of the genitourinary collecting system
during MDCT urography with enhanced CT digi-
tal radiography: nonsaline versus saline bolus.
AJR 2006; 186:122–129
17. Choyke PL, Bluth EI, Bush WH Jr, et al.; Expert
Panel on Urologic Imaging. Hematuria. Reston,
VA: American College of Radiology, 2005; www.
guideline.gov/summary/summary.aspx?doc_
id=15763. Accessed January 12, 2010