Genitourinary Imaging Chou et al.
CT Urethrography and Virtual Urethroscopy
Chen-Pin Chou1 Jer-Shyung Huang1 Ming-Ting Wu1,2 Huay-Ben Pan1,2 Fong-Dee Huang3 Chia-Cheng Yu3 Chien-Fang Yang1,2
Chou C-P, Huang J-S, Wu M-T, Pan H-B, Huang F-D, Yu C-C, Yang C-F
CT Voiding Urethrography and Virtual Urethroscopy: Preliminary Study with 16-MDCT
OBJECTIVE. The purpose of this study was to demonstrate CT voiding urethrography and CT virtual urethroscopy. Fourteen CT voiding urethrography examinations on 13 men (mean age, 30 years) were prospectively performed with 16-MDCT. The clinical diagnoses of those patients included urethral injury, urethral stricture, and hypospadia. The CT voiding urethrogram was obtained with transverse CT of the voiding, contrast-filled urethra and display of 2D multiplanar and 3D virtual images. CONCLUSION. The full urethral structure was clearly shown by CT voiding urethrography and virtual urethroscopy in all patients. The results of CT voiding urethrography and conventional methods correlated closely with the urethral diseases being imaged. ost diagnostic imaging of the urethra continues to be performed using conventional radiography with luminal distention by iodine contrast media. However, radiographic contrast material–enhanced studies are invasive and do not provide information about periurethral tissue. Other, more modern imaging techniques such as sonography and MRI can contribute, in some specific circumstances, to the diagnosis of urethral diseases. Sonography has a small field of view, and the technique is operator-dependent. MRI is not widely used to examine the urethra because the technique is somewhat complex and expensive. CT is used only rarely to study the urethra. Its usefulness is limited to the evaluation of inflammatory fluid collections or the identification of gas formed during necrosis or trauma . Recent advances in MDCT, rapid image acquisition, and software have made 2D and 3D reformatted images available for the newer diagnostic techniques. These techniques have been applied to many organs, including the colon, bronchus, stomach, and urinary bladder [2, 3]. The thin-section transverse images and high scanning speed of CT have led to the development of promising new techniques for urethral evaluation: CT voiding urethrography and virtual urethroscopy. With these techniques, the voiding, contrast-filled urethra is scanned with 16-MDCT in approximately 6 sec. Real-time 3D rendering of CT images is performed to visually simulate urethroscopic examination. In this study, we investigated the technique of 16-MDCT in the detection of urethral diseases. Subjects and Methods Patients
From January 2003 to May 2004, 13 men (age range, 18–50 years; mean, 30 years) in whom urethral diseases were suspected were referred from the genitourinary or emergency department for urethral imaging studies. In total, 14 CT voiding urethrography examinations were performed. One man with hypospadia underwent CT voiding urethrography before and after surgery. The micturating condition of patients was checked before examination. If the patients reported an inability to void before and during CT examination, they were not considered for this study. Our series included suspected urethral in-
Received January 18, 2004; accepted after revision September 15, 2004. Supported by Kaohsiung Veterans General Hospital research program (VGHKS93-82).
of Radiology, Kaohsiung Veterans General Hospital, 386 Da-Chung First Rd., Kaohsiung 813, Taiwan, ROC. Address correspondence to C.-P. Chou (email@example.com). Taipei, Taiwan, ROC. Medicine,
2National Yang-Ming University School of 3Department
of Urology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan, ROC.
AJR 2005;184:1882–1888 0361–803X/05/1846–1882 © American Roentgen Ray Society
AJR:184, June 2005
B = bulbous urethra. 40 H. All patients were alert and oriented and had stable vital signs when they arrived at the radiology department. Patients with pelvic fractures were supine while scanned because they could not lie After an anteroposterior topogram had been obtained for slice selection. urethral stricture. for which both supine and prone scanning is necessary. All serial thin-section images of the lower urinary tract were obtained using a 16-MDCT scanner (Somatom Sensation 16. and diastasis of bilateral sacroiliac joints and symphysis pubis.0-mm reconstructed slice width at intervals of 0. M = membranous urethra. No urethral interruption or contrast medium extravasation is noted.7 mm (0. and a total scan length of 16–20 cm. Pe = penile urethra. radiologists performed interactive intraluminal navigation from the urinary bladder to the urethra. Virtual endoscopy was performed using surface-rendered or volume-rendered techniques. Two-dimensional curve reformatted sagittal image using maximum intensity projection shows normal segmental anatomy of male urethra. urinary bladder. Interactive standard axial. Scanning parameters included a 0. With CT endoscopic fly-through navigator software. Siemens). variable ranges were tried for each patient to optimize the setting. sagittal. Three-dimensional volume-rendered urogram shows comminuted fractures of left ilium bones extending to left acetabulum with displaced bone fragments. prone. Sixty milliliters of IV iopamidol (Iopamiro 300. we increased the rate of IV fluid administration to accelerate urine production and distend the urinary bladder satisfactorily. Because the attenuation coefficient of the urethral lumen varied from patient to patient. In contrast to CT colonography or CT cystography. a 1.3-mm overlap). The patients signed informed consent forms for CT voiding urethrography. B. We adjusted the attenuation coefficient range for voxel categorization to the contrast material in the urethra until the normal mucosal surface appeared smooth and no noise was seen in the lumen. Siemens) with manufacturer-provided software that allows generation of 2D maximum intensity projection.75-mm collimation × 16detector array. Patients wore urinary bags over their penises to collect urine and avoid wetting the CT machine. 2A).
The transverse thin sections were transferred to a workstation (Syngo. Urethra (arrows). we directly infused 400 mL of diluted watersoluble iopamidol via catheters. No oral contrast medium was used in our series. The new vessel-view tool of the Syngo workstation is a semiautomatic protocol-driven analysis
Image Acquisition Patient Preparation
CT voiding urethrography was performed as an independent CT examination (n = 13) or as part of serial CT examinations (n = 1). 1).5-sec gantry rotation speed. For pelvic trauma patients who might need emergent surgery. and 3D volume-rendered technique (Fig. reconstruction. 120 mA. We performed CT when the patient expressed a strong desire to void.
AJR:184. June 2005
. they began scanning. the patients were asked to press a handheld wireless bell controller when they began voiding. 1. A. As soon as technologists heard the bell. We did not perform prevoiding CT routinely because we wanted to avoid exposing the patients to additional radiation.—Imaging of urethra with 2D and 3D techniques in 27-year-old man after vehicle accident. CT urethrography requires scanning in only one position. and coronal reference images were obtained automatically during navigation (Fig. 2D multiplanar
Fig. a total scanning time of 6 sec. The urinary bladder was opacified by renal excretion of iodine contrast medium administered IV (n = 13) or through infusion into a suprapubic tube (n = 1). highquality scanning mode (0. If the patient had suprapubic tubes or Foley urethral catheters. and 120 kVp). the upper limit range was 700–850 H. CT was performed with the patient prone (n = 9) or supine (n = 5).CT Urethrography and Virtual Urethroscopy
juries. The urethra was evaluated with 2D transverse images and a soft-tissue window setting (window level. Data acquisition was craniocaudad and resulted in about 300 transverse images for each scan. The CT topogram was used as a pelvic radiogram. 3D shaded-surface display. P = prostatic urethra. We urged the patients to drink water or increased their IV saline fluid supplement to distend the urinary bladder rapidly. window width. 512 × 512 matrix. The lower limit of the attenuation coefficient range for voxel categorization on virtual urethroscopy was 200–250 H. and ureters (arrowheads) are shown well. 300 H). Bracco) was administered 30 min before scanning. and hypospadia. Two experienced abdominal radiologists (who were trained in interactive navigation and interpretation of 3D virtual-reality CT colonography or CT cystography and were unaware of the results of other examinations) prospectively and independently interpreted the CT voiding urethrography.
Images on CT voiding urethrography were of excellent quality. 2B). We easily could find the urethral path distance by clicking either the multiplanar reformation or the volume-rendering techniques to place the first seed point and terminal point. or required optic urethrostomy for urethral stricture. reference imaging segments are synchronized to position of pointer. had a Fo-
Results The time required for the CT procedure ranged from 4 to 20 min (mean. 10 min). and coronal reference images. Display panel of 3D volume-rendered virtual urethroscopy shows axial. Cystourethroscopy was performed if the patient sensed a foreign body in the urethra. we did not routinely obtain VCUG.
Further Urethral Study
Eleven men were assessed using conventional retrograde urethrography on the same day. June 2005
ley catheter placed because of urethral injury. A. the so-called ribbon multiplanar reformation. Vessel-view display panel shows entire urethra with 2D curve multiplanar reformation technique and measurement tools. The required longitudinal multiplanar reformatted section view and cine imaging are created using the angle slider to rotate the image plane.Chou et al.—37-year-old man with straddle injury. Focus pointer (arrows) displays as line in vessel navigator. depending on how soon patients began to void. with adequate contrast filling of both the anterior and the posterior ure-
Fig. C. Maximum transverse diameter and area in axial cross-section of urethra are determined automatically by clicking required position of urethral path. Fly path of virtual urethroscopy is identified on synchronized multidirectional reference images. sagittal. CT voiding urethrography examinations were completed successfully for all patients. This tool also works well for the urethra. The vessel navigator displays a longitudinal cut along the centerline of the urethra. Also. No significant difference in image quality was noted between supine and prone positioning. with multiplanar reference images along the curve of the urethra (Fig.
Three men were examined with cystourethroscopy by experienced urologists on the same or next day.
tool for CT angiography. 2C). maximum luminal diameter and luminal area could be measured perpendicularly to the urethral axis (Fig. Verumontanum is viewed at 6-o’clock position (arrow). 2.
1884 AJR:184. We could create urethral boundaries using semiautomatic segmentation functions. An experienced abdominal radiologist interpreted the conventional urethral examinations without knowing the results of CT voiding urethrography. When focus pointer is moved. B. Because CT voiding urethrography obtains antegrade urethral images similar to voiding cystourethrograms (VCUG) and we did not wish to expose the patients to additional radiation. 9 min). The time required for interpretation of the CT urethrographic data ranged from 6 to 20 min (mean.
The patient underwent corrective surgery with flap reconstruction. and the retrograde urethrograms showed contrast medium extravasation in the bulbous urethra. CT voiding urethrography was superior to conventional examinations for imaging of pathologic anatomy and measurement of lesions and created greater diagnostic confidence. an intraluminal blood clot. CT voiding urethrography provided useful information before and after surgery. 5). IV
AJR:184. Patient 13 had undergone plastic surgery for hypospadia 30 years earlier and complained of postvoid dripping. The CT voiding urethrography protocol in this study involved 0. IV Clinical History Blunt perineum injury Findings of CT Voiding Urethrography Contrast medium extravasation. After 3 months. IV
Bleeding from the urethra after sexual Contrast medium extravasation in intercourse penile urethra Traumatic urethral stricture Membranous urethra stricture
Surgically repaired hypospadia 30 yr Hypospadia at middle shaft of penis Retrograde urethrography: failure to previously and a diverticulum within penile skin insert a Foley catheter because of coverage narrow meatus opening and pain Difficult voiding 5 mo after corrective Stricture in penile urethra surgery Cystourethroscopy: optic urethrotomy for penile urethral stricture
Prone. The more thinly collimated transverse images and the subsequent better quality of the reformatted images should further increase the ability of CT to depict the urinary tract accurately . contrast medium extravasation from the penile urethra was detected with CT voiding urethrography but was missed on retrograde urethrography (Fig. IV
Blunt perineum injury Blunt perineum injury
Complete transection of urethra after Short segment narrowing at surgical realignment bulboprostatic anastomosis region Contrast medium extravasation in bulbous urethra
Supine. IV Prone. At a normal urinary flow rate of 15 mL/sec for men. Patient 12 experienced bleeding from the urethra after sexual intercourse. cystourethroscopy. 3). no urethral injury Negative Negative Retrograde urethrography: negative Retrograde urethrography: negative Retrograde urethrography: posterior urethra cannot be evaluated well Retrograde urethrography: contrast medium extravasation in bulbous urethra Cystourethroscopy: mucosa perforation in bulbous urethra Retrograde urethrography: negative Retrograde urethrography: posterior urethra cannot be evaluated
7 8 9 10
24 22 23 26
Prone. The final diagnosis was based on retrograde urethrography. June 2005
. Patient 9 had a history of surgical realignment for type 3 urethral injury with disruption of the urogenital diaphragm.CT Urethrography and Virtual Urethroscopy thra in all patients. Discussion CT voiding urethrography is a technique similar to conventional VCUG. IV Supine. or surgical findings (Table 1). For three cases of urethral stricture. A blood clot at the site of injury was found in two of the three patients with urethral injury. CT voiding urethrography revealed stricture in the membranous urethra with proximal urethral dilatation (Fig. High-speed 16-MDCT
TABLE 1 Patient Data and Examination Findings
Patient No. IV Prone. IV Supine. The retrograde urethrograms did not allow proper evaluation of the posterior urethral stricture. Patient 12 had had a urethral injury and a complicated urethral stricture 1 year earlier. 4).75-mm collimation and revealed the entire urethra in 6 sec. Patients 1 and 10 had a straddle injury. Pelvic fractures were noted in three. For urethral injury. A type 5 urethral injury according to the classification by Goldman et al. CT voiding urethrography and conventional methods were of similar accuracy. urinary bladder rupture after primary suture 2 wk earlier Blunt perineum injury Blunt perineum injury Vehicle accident
3 4 5 6
37 32 35 30
Prone. IV Prone. CT voiding urethrography showed penile hypospadia and a diverticulum within the penile skin coverage (Fig. irregular mucosa surface at injury region. CT voiding urethrography also revealed extravasation. and mucosal abnormality (Fig. 6B). CT voiding urethrography showed a short-segment urethral stenosis at a bulboprostatic anastomosis. the time needed to void 400 mL is longer than 20 sec. no cystography: mass effect at right urethral injury vesicoureteric junction. suprapubic Foley Falling injury catheter
11 12 13
50 18 38
Supine. and blood clot in bulbous urethra Negative Additional Study Retrograde urethrography: contrast medium extravasation in bulbous urethra Retrograde urethrography: negative
Supine.  was diagnosed in two patients. 1 Age (yr) 25 Position and Method of Contrast Administration Prone. IV
Retrograde urethrography: negative Retrograde urethrography: negative Cystourethroscopy: negative
Foreign body sensation when voiding Negative
Bladder wall contusion and blood clot Retrograde urethrography and at right vesicoureteric junction. IV
Vehicle accident. Five months later. 6A). IV Prone. Nine patients with clinically suspected urethral injury underwent retrograde urethrography. Retrograde urethrography was unsuccessful because of a small meatus opening and pain intolerance. IV Prone. a penile urethral stricture requiring urethrotomy developed (Fig.
transverse CT images showed the full extent of the urethra. D. kidney to urethra. CT voiding urethrography improved patient compliance. June 2005
. Because CT easily depicts the high attenuation produced by contrast material. B. Retrograde urethrogram shows contrast medium extravasation (arrow) in bulbous urethra. Display of CT data in the form of virtual urethroscopy images affords a number of advantages over transverse CT images alone. Virtual urethroscopy image based on surface rendering shows mucosal disruption (arrows) in bulbous urethra. Patients need to understand and follow the instructions of technologists. Compared with retrograde urethrography and conventional cystourethroscopy. and luminal area. Multiple views. Urethrocavernous and urethrovascular reflux (arrowhead) also were noted. A. Patient compliance is an important determinant of the success of CT voiding urethrography. CT voiding urethrography is more convenient because patients are required to adopt only one position and the scanning time is only 6 sec.
Fig. Variations in patient positioning and penile traction during imaging can greatly alter the radiographic appearance of the urethra and strictures. distance from the urethral meatus.—25-year-old man who presented with hematuria after blunt perineum contusion. Good communication between patients and CT technologists during the examination also is necessary. We preferred to position patients prone with pillows below their abdomen to increase intraabdominal pressure and enhance the force of micturation. can scan the entire urethra and urinary bladder in 6 sec. Radiologists should know that the patients have no difficulty with voiding. In this study. diluted contrast material is better appreciated on CT images than on conventional urethrograms. Conventional cystourethroscopy image reveals bleeding and perforation at 5. Patients should be interviewed before the examination to evaluate their acceptance of it. Volume-rendered CT voiding urethrogram obtained with contrast infusion from suprapubic tube shows contrast extravasation and irregular mucosal surface (arrow) in bulbous urethra. CT voiding urethrography is more accurate with computer-aided tools for urethral measurement. A supine scanning position was preferred for patients with multiple pelvic fractures. urethral imaging with CT voiding urethrography and virtual endoscopy can reduce organ injury and patient suffering. In our experience. When multiple pelvic fractures and associated patient discomfort are present. and patients with complex pelvic fractures do not need to change positions. CT voiding urethrography could play a role in lower urinary tract evaluation for clinically stable patients. Exact comparison of the luminal size and stricture length on clinical followup is possible.
1886 AJR:184. the oblique position for conventional radiography may not always be possible. 3. Complete evaluation of the entire urinary tract. contrast media. Some patients who could not tolerate conventional urethral examinations could accept CT voiding urethrography. may be required on conventional radiographs . The technique should not be used on patients with acute major trauma or acute pelvic fracture unless they already have shown an ability to void. including bilateral oblique. or instruments can be avoided with use of axial and multiplanar images. The patient’s position is not critical with high-quality 3D images. The scan processes or imaging quality in our study were the same whether patients were prone or supine. Missing of lesions obscured by bone structures. C. Radiologists should participate in the whole procedure and interpret the real-time images on monitors.to 7-o’clock position of bulbous urethra. The vessel view is longitudinal along the curve of the urethra and accurately measures stricture length. Conventional radiography requires positioning of the patient’s urethra and avoidance of overlapping with bone structures.Chou et al. is easy with the newly developed 16-MDCT.
Reflex contraction of the pelvic muscle because of forceful injection of the contrast material may lead to a false-positive
diagnosis of stricture .
Virtual urethroscopy allows data from more than 300 slices of CT images to be compressed into one interactive data set. difficulty in detecting flat
Fig. In this study.—50-year-old man with urethral bleeding after sexual activity. Multiplanar coronal reformatted image (curved along urethra) shows posterior urethral stricture (arrow) and prostatic urethral dilatation (arrowhead). he sustained urethral injury 1 year earlier in motor vehicle collision. Contrast medium extravasation (arrow) in penile urethra is identified on CT voiding urethrogram. Standard practice dictates that trauma and stricture of the male urethra be evaluated with retrograde technique because of the belief that
only it produces sufficient distention. the disadvantages of CT virtual cystoscopy versus conventional cystoscopy include exposure to radiation. such as in CT voiding urethrography. June 2005
. some technical problems remain. with occasional resultant systemic complications such as sepsis and anaphylaxis. Retrograde urethrography is not a physiologic examination. 5.
AJR:184.—18-year-old man with urethral stricture. For urologists who are not familiar with transverse images. Although retrograde urethrography also can be performed during CT. Contrast material often is injected under pressure to overcome the resistance of a stricture. 4. we showed in several instances that the new CT technology can show clear urethral imaging sufficient for diagnoses. Rapid and forceful injection of the contrast medium in retrograde urethrography may lead to rupture of the mucosal barrier and extravasation of the contrast material into the systemic circulation. vessel view. According to previously published articles.CT Urethrography and Virtual Urethroscopy
Fig. Retrograde urethrogram shows no finding. These include inadequate contrast medium filling and radiation exposure to the operators. CT voiding urethrography and virtual endoscopy provide a global orientation for focal findings and aid navigation for endoscopists. The data set can be manipulated easily for multidirectional viewing and can be recorded as cine files . B. A.
McGuire EJ. New imaging of the anterior male urethra. Virtual cystoscopy: early clinical experience. The benefits of CT voiding urethrography and virtual endoscopy over conventional imaging include accurate measurement of lesions. Settles M. Goldman SM. et al. Argiro V.
1. Retrograde urethrogram: diagnostic aid and hazard. it may become possible to reduce the radiation dose by adjusting CT parameters. Morey AF. experience with CT voiding urethrography is limited. Sandler CM. Appl Radiat Isot 1999. Fenlon HM.
A theoretic concern with MDCT voiding urethrography. Vining DJ. The effective dose of radiation from CT voiding urethrography for an average man is approximately 5 mSv. Beer A. June 2005
. The technical limitations are the same for CT voiding urethrography as for VCUG.28:180–186 2. Abdom Imaging 2003. 2005
A data supplement for this article can be viewed in the online version of the article at: www.htm. McAninch JW.Chou et al. vessel view.
AJR:184. Simple VCUG cannot provide pressure as great as that provided by retrograde urethrography or double-ballooncatheter urethrography. Lammle M. J Urol 1973. Thus. as is done in low-dose CT colonography. RadiologyInfo Web site. Shrimpton PC. Stelts D. Pavlica P. in comparison with VCUG. Paulson DF. J Clin Ultrasound 1996. However. When VCUG is used for a child of 5–10 years old. a measurement of radiation exposure that takes into account the volume of irradiation . Dosimetry for optimization of patient protection in computed tomography.110:462–466 9. depiction of extraluminal anatomic landmarks. radiologists need to select patients carefully. Radiology 1997. and lack of biopsy .ajronline. Michael L. Geleijns J.6 mSv . Imaging of the male urethra for stricture disease. CT voiding urethrogram.29:361–372 7. The dose from MDCT can be estimated from the dose–length product. Cohan RH. et al. Pediatric voiding cystourethrogram. Analysis of thin-section axial CT images and associated findings such as intraluminal blood clots and mucosal irregularity may improve the accuracy of diagnosis. from the kidney to the urethra. Liu K. good patient compliance. is the possibility that patients will receive more radiation.178:1483–1488 10. Caoili EM. The combination of retrograde urethrography and CT voiding urethrography may help radiologists avoid potential pitfalls. Effective antegrade imaging may be impossible in patients with complete urethral disruption and severe posttraumatic urethral stricture . and some urethral abnormalities can be missed with CT voiding urethrography.radiologyinfo. Reliability of MR imaging-based virtual cystoscopy in the diagnosis of cancer of the urinary bladder. and radiologists might misinterpret extravasation as a negative finding or. et al. Panzer W. Ahari HK. Menchi I. Tosi G. As experience with CT voiding urethrography increases. Korobkin M. Available at: http://www. He arranged another surgical correction because of dripping after voiding.—38-year-old man with history of hypospadia after plastic surgery 30 years earlier. J Urol 1997. shows ectopic urethral orifice (black asterisk) in middle of penile shaft and diverticulum (arrow) within penile skin coverage (arrowheads). Accessed February 3. Bell TV. Perspective volume rendering of CT and MR images: applications for endoscopic imaging. Urinary tract abnormalities: initial experience with multi-detector row CT urography. Blunt urethral trauma: a unified. Radiology 1996. Radiol Clin North Am 2002. if from the bulbous urethra. Urethral stricture (arrow) developed 5 months after surgical correction. Peterson LJ. anatomical mechanical classification.157:85–89 5. A.166:409–410 4. Jessen KA. AJR 2002.205:272–275 8. To our knowledge.222:353–360 6. The volume of contrast medium extravasation in CT voiding urethrography is usually less than that in retrograde urethrography.24:473–479 11. Zagoria RJ. Some patients are psychologically inhibited from micturating because of the required investigational procedures and surroundings. and the ability to survey the whole urinary tract.org. as a reflux into a normal Cowper’s duct. a large study of various urethral diseases is needed to determine the clinical value of CT voiding urethrography. the effective radiation dose is about 1. without magnification or distortion. CT voiding urethrography has not been reported previously. Ultrasound evaluation of the male urethra for assessment of urethral stricture. Currently. Corriere JN Jr. conventional urethral examinations should be performed to confirm the diagnosis in doubtful cases. CT cystoscopy: an innovation in bladder imaging. Conventional urethral imaging is challenged by the new CT techniques. Because of the excessive time needed to create virtual images. production of both transverse and 3D images of urinary tract abnormalities.org/ content/v-cystourethrogrm-pd. Mullin EM. Hussain S.
or small mucosal lesions. Beaulieu CF.50:165–172 12. lack of information on the color and texture of the mucosa. Barozzi L. B. White asterisk is at expected location of meatus. Radiology 2002.199:321–330 3. and urethral pathology has not been described using virtual urethroscopy. Rubin GD. 6. AJR 1996.