Niskodozni protokol CT urografije u obradi bolesnika s makrohematurijom

Ćurić, Josip (2010) Niskodozni protokol CT urografije u obradi bolesnika s makrohematurijom. PhD thesis, Sveučilište u Zagrebu.

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Abstract

Introduction: The CTU has been proven as a „one stop shop“imaging modality that offers the complete analysis of the urinary tract in the course of only one examination. The shortcomings, when compared to the conventional IVU that was for long time considered a „golden standard” in the evaluation of the patients with hematuria, are the relatively high radiation dose along with its inability to visualize the optimally distended and opacified urinary tract in only one scanning phase. In the literature many different patient preparation protocols have been proposed in order to optimize the distension of the urinary tract but in fact none of them has been proven to really work. Introduction of the „split bolus” technique that allows synchronous acquisition of nephrographic and excretory phases has led to significant reduction in the patient’s radiation dose when compared to the standard three-phasic scanning protocol of examination. Aim of the study: To monitor the patient radiation dose during „split bolus“ MSCT urography and during conventional IVU. To evaluate the influence of different oral hydration protocols (20min versus 60 min prior to examination) in visualization of different urinary tract segments. Results: Distal ureter: in the group of patients that were orally hydrated with 1L of water 1 hour before the MSCTU examination the distal ureter was fully visualized in 86.2%, near full visualization (99%-80%) was achieved in 7.4% and visualization of less than 79% of the ureter was achieved in 6.3% of patients. In the group of patients that were orally hydrated with 1L of water 20 minutes prior to the MSCTU examination the percentage of fully visualized distal ureters, near full visualization (99-80% ) and visualization of less than 79% were 44.4%, 12.7% and 42.6% respectively. In the group of patients that have undergone conventional IVU examination the results of visualization of distal ureter were as follows:41.6%.12.2% and 45.6%. Proximal ureter: in the group of patients hydrated with 1L of water 60 minutes prior to the CT examination the proximal ureter was fully visualized in 91.4%, near full visualization was achieved in 4.6% and less then 79% of its course in further 4% of the patients. The results in the group of patients who received oral hydration 20 minutes prior to CT examination were 72.8%, 11.8% and 15% respectively. In the group of patients that have undergone conventional IVU the results were: 68.4%, 8.6% and 23%. Renal pelvis: in the group of patients hydrated 60 minutes prior to CT examination it was fully shown in 99.45% and less then 79% of it was visualized in 0.5% of the patients. The results in the group of patients who received oral hydration 20 minutes prior to CT examination were 90%, 5% and 5% respectively. In the group of patients that have undergone conventional IVU the results were 95.4%, 4% and 0.5% respectively. Calices: in the group of patients given oral hydration 60 minutes prior to CT examination calices were fully visualized in 91%, near full visualization was achieved in 4.6% and less then 79% visualization was achieved in 4% of the patients. In the group of patients given oral hydration 20 minutes prior to the CT examination the results were 70%, 19.6% and 9.9% respectively. In the group of patients that have undergone conventional IVU the results were 76%, 9.7% and 14.3%. The total number of fully visualized urinary tract segments was significally higher in the group of patients given oral hydration 60 minutes prior to the CT examination compared to the two other groups of patients (p<0.01). There was no significant difference between the group of patients given oral hydration 20 minutes prior to the CT examination and patients that have undergone conventional IVU. The mean radiation dose was 12.07 mSv in the group of patients that were examined with „split bolus“ MDCTU protocol in comparison to 6.74 mSv in the group of patient that have undergone conventional IVU. Conclusion: Oral hydration given 60 minutes prior to the MDCTU examination has been proven to give excellent results in visualization of all segments of urinary tract. The radiation dose was 1.8 times higher for patients undergoing MSCTU when compared to conventional IVU. Maintaining the reasonable indication range, using fewer scanning phases during examination and applying different imaging protocols suited for particular indications could all help in lowering radiation risk and radiation doses to the patients.

Abstract in Croatian

Uvod: CTU se pokazao metodom koja omogućuje cjelokupnu obradu urotrakta u jednom aktu. Nedostaci CTU u odnosu na IVU, koja je dugo vremena bila „zlatni standard“ u obradi bolesnika s hematurijom, su relativno velika doza zračenja te nemogućnost prikaza optimalno distendiranog i opacificiranog urotrakta u jednoj seriji snimanja. U literaturi se opisuje veliki broj postupaka pripreme bolesnika koji poboljšavaju distenziju urotrakta, što zapravo znači da ni jedan ne zadovoljava u potpunosti. Objedinjavanjem parenhimske i ekskrecijske faze u „split bolus „ tehnici CTU značajno je smanjena doza zračenja u odnosu na standardni trifazični protokol CTU. ----- Ciljevi istraživanja su: izmjeriti doze zračenja kod bolesnika kod kojih je rađena "split-bolus" MSCT urografija te kod bolesnika kod kojih je rađena intravenska urografija i utvrditi uspješnost pojedinih protokola oralne hidracije (20 min, 60 min) CTU te IVU u prikazu pojedinih segmenata urotrakta. ----- Rezultati: Distalni ureter: u skupini bolesnika koja je hidrirana s litrom vode 1 sat prije MSCTU distalni ureter je kompletno prikazan u 86,2% bolesnika, gotovo kompletno (99%-80%) u 7,4% bolesnika te u manje od 79% tijeka u 6,3% bolesnika. U skupini bolesnika hidriranih 20 minuta prije pretrage postotak kompletno, gotovo kompletno te distalnih uretera prikazanih u manje od 79% tijeka je bio 44,4%, 12,7% te 42,6%. U skupini bolesnika kod kojih je rađena IVU rezultati su 41,6%, 12,2% i 45,6%. Proksimalni ureter: u skupini bolesnika koja je hidrirana 60 minuta prije pretrage proksimalni ureter je kompletno prikazan u 91,4%, gotovo kompletno u 4,6% te u manje od 79% tijeka u 4% bolesnika. Rezultati u skupini bolesnika hidriranih 20 minuta prije MSCTU su 72,8%, 11,8% i 15%. U skupini bolesnika kod kojih je rađena IVU rezultati su 68,4%, 8,6% i 23%.Pijelon: u skupini bolesnika koja je hidrirana 60 minuta prije pretrage pijelon je kompletno prikazan u 99,45% bolesnika a u manje od 79% tijeka u 0,5%. U skupini bolesnika hidriranih 20 minuta prije pretrage rezultati su bili 90%, 5% i 5%. U skupini bolesnika kod kojih je rađena IVU rezultati su bili 95,4%, 4% i 0,5%. Kaliksi: u skupini bolesnika koja je hidrirana 60 minuta prije pretrage kaliksi su kompletno prikazani u 91% bolesnika, gotovo kompletno u 4,6% te u manje od 79% u 4% bolesnika. U skupini bolesnika hidriranih 20 minuta prije pretrage rezultati su 70%, 19,6% te 9,9%. U skupini bolesnika kod kojih je rađena IVU rezultati su 76%, 9,7% te 14,3%. Broj kompletno prikazanih pojedinih segmenata urotrakta je statistički značajno veći u skupini bolesnika hidriranih 60 minuta prije MSCTU u odnosu na ostale skupine bolesnika (p<0,01). Između skupine bolesnika hidriranih 20 minuta prije MSCTU i skupine bolesnika kod kojih je rađena IVU nije bilo statistički značajne razlike. Prosječna efektivna doza zračenja kod bolesnika kod kojih je rađena MSCTU „split bolus“ protokolom je 12,07 mSv a kod bolesnika kod kojih je rađena IVU 6,74 mSv. ----- Zaključak: Oralna hidracija bolesnika 60 min prije CT urografije je metoda koja daje odlične rezultate u prikazu svih segmenata urotrakta. Doza zračenja u bolesnika kod kojih je rađena MSCTU je 1,8 puta veća od doze zračenja tijekom IVU. Striktno poštivanje indikacija za CTU, smanjenje broja faza tijekom CTU, odnosno postojanje nekoliko različitih protokola CTU za različite indikacije je najbolji mogući način za smanjenje radijacijskog rizika i zračenja bolesnika.

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