USE OF CONTRASTED COMPUTERIZED AS A SURROGATE

FOR NUCLEAR MEDICINE RENOGRAM TO CATEGORIZE

RENAL FUNCTION IN THE SETTING OF URETEROPELVIC
JUNCTION OBSTRUCTION

JACOB T. ARK, MD, CHRISTOPHER R. MITCHELL, MD, TRACY P. MARIEN, MD, AND S.
DUKE HERRELL, MD
VANDERBILT UNIVERSITY MEDICAL CENTER, DEPARTMENT OF UROLOGIC SURGERY,
NASHVILLE, TN 37232
 OBJECTIVES:

• To use basic measurements on contrasted computerized tomography (CT) to reliably determine

whether a kidney with UPJO is definitively functional (>30% differential real function [DRF]) or
nonfunctional (<10% DRF), obviating the need for nuclear medicine renogram (RG) to
determine DRF.
 HYPOTHESIS

• We hypothesize that in patients with UPJO warranting operative intervention, contrasted CT

measurements can be used to reliably estimate correlating DRF on RG for definitively
nonfunctional kidneys (<10%) and definitively functional kidneys (>30%), obviating the need
for RG prior to nephrectomy or pyeloplasty, respectively.
 METHODS:
• This is a single institution, retrospective cohort of patients diagnosed with UPJO who underwent either
pyeloplasty or nephrectomy between december 2004 and december 2014.
• Included patients had both preoperative MAG3 RG and contrasted CT within 180 days of each other.
• Exclusion criteria included solitary kidney, baseline creatinine greater than 1.5 71 mg/dL, dialysis, and
known ureteral reflux. Patients with stents or nephrostomy tubes at the time of imaging were excluded
from this study to maximize clinical applicability, as most patients initially presenting with UPJO will
not have a stent or nephrostomy.
• Only MAG3 RGs were included.
• Contrasted CT imaging was reviewed in the arterial phase only
 MEASUREMENTS ON CT
• Renal length- coronal film or axial (if coronal film not available)
• Renal lateral width and AP diameter- axial film, at the level of renal hilum
• Parenchymal thickness- 6 measurements , Average
• 1st three- once the superior collecting system is delineated ( Superior Axial, Superior lateral and superior medial)
• 2nd three- at the final cross section where the collecting system was clearly delineated (inferior lateral, inferior axial, inferior medial)

• The same concept was used to measure cortical thickness.

• Cortical and medullary enhancement were measured, utilizing an ellipse that spanned 75% of the thickness to maximize the
average accuracy while minimizing interference of surrounding tissue
• To promote standardization of technique, six measurements were taken per kidney in the same regions where tissue
thickness was measured.
• Only arterial phase is used
 CALCULATING DIFFERENTIAL RENAL
MEASUREMENTS
• After renal measurements were obtained on CT, differential renal measurements (DRM) were
evaluated for their strength of correlation to RG DRF.
• CT DRM were calculated using '100*(RRM/ (RRM+ LRM)).’
• All DRM calculations solved for the right kidney, whether or not it was obstructed.
 STATISTICS

• Data were analyzed using pearson’s correlation coefficient, consistent with prior 132 studies
comparing CT and RG, and linear regression compared with p<0.05 133 considered statistically
significant
• Calculations were completed using 134 XLSTAT v2015.4.01.21576 (addinsoft inc., Brooklyn,
NY). Receiver operator 135 curve (ROC) calculations were confirmed using stata v11.2
(statacorp LP, 136 college station, texas).
 RESULTS

• Majority were female 29/49

• Median age was 37.
• Time gap between ct and rg was a median of 42 days
• Pyeloplasty was performed in 43 cases, 24 of them on the right.
• Nephrectomy was performed in 6 cases, 3 of them on the right
• Multiple combinations of CT measurements were used to calculate various DRMs.
• These CT DRMs were then evaluated for their strength of correlation DRF on RG.
• For each ct drm, a pearson’s correlation coefficient between ct drm and rg drf was calculated
• The strongest correlation between CT and RG was achieved using the CT DRM of cortical area
multiplied by cortical HU (r=0.90, p<0.001).
• Cortical area = renal length * average cortical thickness
• Cortical HU was determined by averaging the six cortical HU values.
• Linear regression produced the equation for estimating DRF as y=1.13x–6.86 (p<0.0001), where ‘x’
is the CT DRM, and ‘y’ is the equation-estimated DRF had a RG been performed
• A ROC was generated to determine appropriate cutoff values when using the equation estimated
DRF for identifying definitively functional and nonfunctional kidneys
• ROC analysis revealed that when equation-estimated DRF equaled 10% or less 164 (n=3), it was
100% specific and 100% sensitive (AUC=1.00; 95%ci 0.93–1.0) for a correlating RG DRF of
10% or less.
• When equation-estimated DRF was 40% or higher (n=27), it was 100% specific and 75%
sensitive (AUC=0.929; 95%ci 167 0.83–0.99) for a correlating RG DRF of at least 30%
 DISCUSSION:
• In our current study, 49 patients with UPJO were evaluated and had both a preoperative RG and
contrasted CT in relatively close proximity to each other, making it the largest study comparing CT
and RG in UPJO patients.
• No commercial software was utilized for CT measurements in an attempt to maximize
generalizability.
• We found there exists a strong correlation between RG reported DRF and the differential CT
measurements of cortical area multiplied by cortical HU.
• Fundamentally, it is not surprising that a calculation utilizing “amount of tissue” (i.e. cortical area)
and the “degree to which said tissue expresses function” (i.e. cortical HU) generated the strongest
correlation with RG DRF.
• Although determining how well a CT can estimate specific DRF would be ideal, it is the dichotomy of functional
versus nonfunctional that dictates operative planning in symptomatic UPJO patients.
• Because cutoff values of what defines ‘nonfunctional’ can vary, we applied a 10% cushion both above and below
the proposed AUA algorithm that utilized <20% as nonfunctional
• In order to use CT DRM to estimate DRF without sacrificing confidence in decision-making, we set our sites on
correlating CT measurements with definitively functioning (>30% DRF on RG) and nonfunctioning (<10% DRF on
RG) kidneys.
• Based on ROC analysis, 100% specificity for identifying these definitively functional and nonfunctional kidneys
was maintained when the equation derived from linear regression calculated an equation-estimated DRF of
<10% and >40%, respectively.
• Using these values, over 60% (30/49) of RGss obtained in the cohort would have been deemed
unnecessary for determining DRF to dictate operative planning.
• It is important to keep in mind, however, that RG is still considered an important part of both
pre- and postoperative UPJO evaluation.
• We do not propose eliminating RG for functional kidneys in which the clinician seeks
confirmation of physiologically-significant obstruction, or desires to have a quantified
preoperative drainage time on which to base evaluation of success
• Otherwise, this means if a symptomatic patient initially presented and received a contrasted CT
indicating a UPJO, appropriate measurements could be used to potentially determine whether the
kidney was definitively functional or nonfunctional, thereby obviating the need for RG to
determine whether nephrectomy or correction of UPJO is the appropriate intervention.
• However, if the equation-estimated DRF falls between the designated cutoff values, a RG would
be advised to drive operative intervention.
• It is important to note that in order to correlate with a >30% DRF on RG, our equation-estimated
DRF was >40%.
• in an attempt to overcome this confusion and heighten clinical applicability, we created the
‘delta score,’ which is the absolute value of the difference in the equation-estimated DRF
• Delta scores <20 indicate a definitively functioning kidney as a score of 20 correlates to an
equation-estimated DRF of 40:60 (with 40% being the equation-estimated DRF cutoff for
identifying a kidney that would be >30% if a RG were obtained).
• Delta scores >80 would be seen in equation-estimated DRFs of 10:90 or worse, correlating to
nonfunctional kidneys
• Delta scores >20 and <80 would merit a RG to determine DRF prior to making operative plans
for UPJO
 LIMITATIONS

• To start, CT has not been shown to accurately determine obstruction.

• the urologist would need to decide if a RG is needed for T½, or if the clinical picture and CT are
definitive enough for the diagnosis

• Single observer
• But inter-observer variability is minimal for CT
 CONCLUSION

• Measurements taken on contrasted CT scans can be used to reliably determine definitively

nonfunctional versus definitively functional renal units in patients with UPJO, potentially
obviating the need for RGs over half the time.
• RGs remain an important preoperative and postoperative imaging study in UPJO patients with
borderline renal function
• in many cases, RG may be unnecessary and result in increased health care 298 expenditure and
delay in definitive treatment.