DIAGNOSTIC PROCEDURES

RADIOGRAPHY
X-rays are electromagnetic waves with photon energies that typically fall between
those gamma rays and UV rays
Radiography is possible because tissues differ in ability to absorb X-rays.
A radiopaque contrast medium is frequently employed to enhance soft tissue
contrast.

Advantages Disadvantages
- Produce anatomic - Use of ionizing Radiation
images of almost any - Poor soft tissue contrast
body part - Use of iodine contrast
- Costs are moderate media
- Modest space
requirements
- Portability
- Many specialists

KUB FILM
A plain film of the abdomen and it is the simplest uroradiologic examination.
It is generally the preliminary radiograph in extended radiologic examinations
It is usually taken with the patient with the patient supine.
It may demonstrate osseous abnormalities, abnormal calcifications or large soft-
tissue masses.
Outlines kidneys: can assess size (varies widely), number, shape, and position,
diameter/length
Average age adult kidney = about 1214 cm long
Children >2y/o = top of L1 bottom of L4
Patterns of calcification in the urinary tract may help to identify specific diseases.

WHY IS IT DONE?
Doctors order KUB FILM when there is a concern about certain types of kidney or
bladder problems. This can show:
size, shape, position of the kidney
abnormalities since birth
presence of blockages or stones
differentiate urologic and gastrointestinal diseases which both produce
abdominal pain
detect air or fluid in the peritoneal space
Corpuz, Dalit, De Vera, Dela Cruz, De Omampo, Guevarra, Gurion, Iguid
 locate a foreign object (something that has been swallowed
tumors

INTRAVENOUS UROGRAPHY
also known as excretory urography (EU)
or intravenous pyelography (IVP)
can demonstrate a wide variety of urinary
tract lesions, permitting demonstration of
lesions otherwise hidden by overlying
soft tissues or obscuring bowel shadows
simple to perform and is well tolerated
useful for demonstrating small lesions in
the urinary tract (eg, papillary necrosis,
medullary sponge kidney, uroepithelial
tumors, pyeloureteritis cystica)

PATIENT PREPARATION
dehydration is to be avoided in infants, debilitated and elderly patients and patients
with diabetes mellitus, renal failure, multiple myeloma or hyperuricemia
bowel cleansing is made according to individual preference

STANDARD TECHNIQUE
Following a preliminary plain film of the abdomen, additional radiographs are taken
at timed intervals after the intravenous injection of iodine-containing contrast
medium.

TECHNIQUE MODIFICATIONS
Radiographic tomography, x-ray imaging of a selected plane in the body, permits
recognition of kidney structures that otherwise are obscured on standard
radiograms by extrarenal shadows (e.g. bone or feces)

Immediate films
taken immediately after the rapid (bolus) injection of contrast
typically show a dense nephrogram and permit better visualization of renal
outlines
Abdominal (ureteral) compression devices temporarily obstruct the upper
urinary tract during EU and improve the filling of renal collecting structures

Delayed films
taken hours later or on the following day, can contribute useful information

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 Upright films
taken with the patient standing or partially erect
reveal the degree of mobility and drainage of the kidneys
if taken immediately after the patient has voided (postvoiding film), show
any residual urine in the bladder.

RETROGRADE UROGRAPHY
a minimally invasive procedure that
requires cystoscopy and the placement of
catheters in the ureters.
a radiopaque contrast medium is
introduced into the ureters or renal
collecting structures through the ureteral
catheters and radiographs of the abdomen
are taken.
must be performed by a urologist or
experienced interventional uroradiologist
Some type of local or general anesthesia
should be used
causes later morbidity or urinary tract
infection.
may be necessary if:
excretory urograms or CT urogram (CTU) are unsatisfactory
if the patient has a history of adverse reaction to intravenous contrast
media
if other methods of imaging are unavailable or inappropriate.

SONOGRAPHY/ULTRASOUND

BASIC PRINCIPLES
Ultrasound images are reection images formed when part of the sound that
was emitted by the transducer bounces back from tissue interfaces to the
transducer.
The sound reected by stationary tissues forms anatomic gray-scale images
The sound reected by moving structures has an altered frequency due to the
Doppler effect.
Power Mode Doppler- more sensitive method of detecting ow and is
available on modern equipment.
Ultrasound images are rapidly updated on a video display, giving an
integrated cross-sectional anatomic depiction of the site studied

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 CLINICAL APPLICATIONS
commonly used for the evaluation of the kidney, urinary bladder, prostate,
testis, and penis
useful for assessing renal size and growth
helpful in triaging patients with renal failure
useful in detection and characterization of renal masses
provides an effective method of distinguishing benign cortical cysts from
potentially malignant solid renal lesions
cost effective method to conrm a diagnosis
may also be used to follow up mildly complicated cysts detected on CT

DOPPLER SONOGRAPHY
useful for the evaluation of renal vessels, vascularity of renal masses, and
complications following renal transplant
It can detect renal vein thrombosis, renal artery stenosis, and ureteral
obstruction

APPLICATION OF SONOGRAPHY
assessment of bladder volume
wall thickness
detection of bladder calculi and tumors

ADVANTAGES DISADVANTAGES
ease of use low signal-to-noise level
high patient tolerance tissue nonspecicity
noninvasiveness limited eld of view
lack of ionizing radiation dependence on the operators
low relative cost skill
wide availability

COMPUTED TOMOGRAPHY SCANNING

CT scan is an imaging technique widely regarded for evaluating the genitourinary
tract.
it combines x-rays and computer calculations to produce precisely detailed
cross-sectional slices of images of the body's tissues and organs.
A thin, collimated beam of x- rays is passed through the patient and captured by
an array of solid-state or gas detectors.

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SPIRAL (HELICAL) CT TECHNOLOGY
uses a slip-ring gantry that rotates
continuously while the patient moves
constantly through the collimated x-ray
beam.
It affords the ability to image during
specific phases of contrast bolus
enhancement, including the ability to
perform CT angiography, and allows
improved image reformations.
paired with powerful computer
workstations so that high-quality three-
dimensional (3D) and multiplanar reformations can be quickly generated and
analyzed.

CLINICAL APPLICATION
commonly used in the evaluation of acute flank pain, hematuria, renal
infection (search for abscess) and renal trauma, and in the characterization
and staging of renal neoplasm.
CT evaluation of renal anatomy and pathology
requires intravenous injection of iodinated contrast media
Contrast media is usually administered as a rapid intravenous bolus for
assessment of renal anatomy or measurement of aortorenal transit
time. Excretion into the collecting structures expected within 23
minutes after initiation of contrast administration.

URETERS
tumor staging and evaluation of the cause and level of obstruction.
Helical CT without oral or intravenous contrast is the preferred imaging
modality for patients with renal colic or suspected urolithiasis

URINARY BLADDER
staging bladder tumors and in diagnosing bladder rupture following
trauma.
Performing CT after filling the bladder with dilute contrast medium (CT
cys- tography) improves the sensitivity of this modality for detecting
tumors and bladder rupture.

PROSTATE
detection of lymphadenopathy, gross extraprostatic tumor extension,
and to delineate prostatic abscesses
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 CT is used for detection of the abdominal location of suspected
undescended testes, for staging of testicular tumors, and in the search
for nodal or distant metastasis.

ADVANTAGES
Wide field of view
Ability to detect subtle
differences in the x-ray
attenuation properties of
various tissues
Good spatial resolution
Anatomical cross-sectional
images
Relative operator independence
Carefully tailored examinations
are essential
Reformatted helical image data
in different planes and in 3D
(valuabe in pre-op. planning)
DISADVANTAGES
Restriction to the transaxial
plane for direct imaging
Tissue nonspecificity
Low soft-tissue contrast
resolution
Need for contrast media (oral
and intravenous). Tissue
contrast is sometimes
unsatisfactory.
Radiation exposure is a
consideration with
multisequence CT imaging.

ENDOSCOPY
Endoscopic inspection allows for identification of calculi, foreign bodies and
mucous plugs, and also has the potential for intubation of ureterointestinal
anastomoses.
it is a surgical approach that uses long, thin scopes with a camera and light
source at their tip (endoscopes) to see directly inside the body's cavities and
organs.
the visuals the scopes provide can be used to diagnose certain urological diseases
and determine the underlying cause behind symptoms.

URETERORENOSCOPY
endoscopy of the ureter up to the renal pelvis for both diagnostic evaluation
and therapeutic intervention
INDICATIONS
DIAGNOSTIC
o Lesions of ureter or renal pelvis
o Hematuria from the upper tract

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 THERAPEUTIC
o Ureteral stone treatment
o Direct vision internal ureterotomy of ureteral strictures
o Endoscopic resection and coagulation of ureteral tumors

Ureterorenoscopes are endoscopes for retrograde insertion into the ureter

antegrade fashion via a percutaneously established nephrostomy
tract.
Rigid ureterorenoscopes- sizes 712F
Semirigid fiberoptic ureterorenoscopes & flexible ureterorenoscopes
in sizes 69F.
The smallest instruments are for diagnostic procedures only.
ureterorenoscopic approach is used more widely, not only for management of
urinary calculi but also for treatment of urothelial tumors.
Insertion is facilitated by dilation of the intramural ureter, either with
sequential plastic dilators of increasing size, which are slid over a guidewire,
or with a balloon dilator catheter.
Diagnostic Ureterorenoscopy
indicated for rare lesions of the ureter or renal pelvis whose nature
cannot be determined with less invasive diagnostic procedures such as
retrograde pyelography, selective urinary cytology, CT, or MRI.

URETHROSCOPY
Endoscopic inspection that identify and aid in treating urethral pathology via a
urethroscope with 0 lens.
Direct visualization of the urethra
Sequential dilation of urethral strictures by inserting catheters of increasing
size exerts shear and tear forces to the mucosa and is likely to produce
extended scarring
Balloon dilation of a stricture with 79F balloon dilators does not exert shear
force
Limited circumferential strictures can be incised under direct vision with an
endoscopic cold knife at 12-oclock position, adequate to allow passage of the
urethroscope.
To identify urethral diverticulum a catheter can be placed through the neck of
the diverticulum to help confirm its location during definitive open surgical
repair
Can be used to direct injection of dye into rare retained mullerian duct cysts
Identify and extract foreign bodies or rare calculi
To access biopsy suspicious lesions
Endoscopic treatment of urethral condylomata
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 CYSTOSCOPY
It is used to view the bladder
Endoscopic inspection of the lower urinary tract requires irrigation,
illumination (fiberoptics), and optics.
optics and illumination are offset by the irrigating and working port
to optimize a complete examination, the rigid endoscope should be rotated,
and 0, 30, 70, and 120 lenses may be required.
Suprapubic pressure facilitates inspection of the bladder dome, which
frequently has an air bubble.
Systematic approach required
Bladder
evaluated at different levels of filling
characteristic: after full distention glomerulations and ecchymoses are
seen

IRRIGANTS
fluid instilled to distend the bladder and improve visualization. (Choice of
irrigant during endoscopic manipulation is important)

Conductive irrigants
o saline and lactated Ringers solution
o inappropriate during traditional endoelectric surgery because the
electrical charge would be diffused by the irrigant.

Nonconductive irrigants
o water and glycine.
o Water has a theoretic advantage of increasing visibility, and because
it is hypotonic, it can lyse tumor cells.

TYPES OF CYSTOSCOPY
Rigid endoscopy
results in discomfort, which can be minimized with 1% lidocaine per
urethra as a local anesthetic.
performed under local anesthesia, but is generally carried out
under general anesthesia
greater variety of instrumentation, better optics, and increased
durability.

Flexible endoscopes
decrease patient discomfort and allow for instrumentation in the supine
rather than the dorsal lithotomy position.
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 maybe without the use of local anaesthesia
DISADVANTAGE: smaller irrigating ports, and do not have a
working sheath. As a result, changing lenses, assessing residual
urine, and repeat evacuation of irrigant cannot be completed
with- out entirely removing the endoscope.

VIDEOENDOSCOPY WITH FLEXIBLE SCOPES

allows patients to visualize normal and abnormal anatomy and thus helps
them understand their pathology.
reduces fluid contact to the urologist and can help reduce potential cervical
neck disease exacerbated with altered posture when endoscopy is performed
without videoendoscopic monitoring.
Instrumentation similar to that used to evaluate the urethra and bladder can
be used to inspect continent urinary reservoirs or conventional ileal loops.

PROSTATE-SPECIFIC ANTIGEN AND OTHER TUMOR MARKERS

PSA is a serine protease in the human kallikrein (hK) family produced by
benign and malignant prostate tissues.
PSA is used both as a diagnostic (screening) tool and as a means of risk-
stratifying known prostate cancers.
PSA is prostate specific, not prostate cancer specific.

PRODUCING FALSE-POSITIVE RESULTS

BPH and prostatitis
Urethral instrumentation and
perineal insults such as prolonged bike ride

normal PSA has traditionally been defined as 4 ng/mL, and the positive
predictive value of a serum PSA between 4 and 10 ng/mL is approximately 2030%.
For levels in excess of 10 ng/mL, the positive predictive value increases from 42%
to 71.4%.
there is no level of PSA below which prostate cancer risk falls to zero.
PSA is rather indicative of a continuum of riskthe higher the level, the higher the
risk.
Artificially Lower the PSA by approximately 50%
Use of medications such as 5-reductase inhibitors
1 mg finasteride formulation marked for alopecia as Propecia
Serum PSA levels have also been noted to be decreased men with high
body mass indexes compared with normal weight men, likely as a result of
hemodilution.

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 PROSTATE CANCER PREVENTION TRIAL RISK CALCULATOR DATA
Race
Age
PSA level
Family History of prostate Cancer
Digital Rectal Examination Result

PRIOR PROSTATE BIOPSY

Principally, only applicable to men under the restriction following:
Age 55 or older
N o Previous diagnosis o f Prostate cancer
DRE and PSA result less than 1 year

STRATEGIES TO REFINE PSA FOR CANCER DETECTION

PSA
Other Risk Factor: History, Age and Race

Goal: to decrease the number of false-positive test results, thus increasing the
specificity and positive predictive value of the test and lead to fewer
unnecessary biopsies, lower costs, and reduced morbidity of cancer detection.
PSA velocity (PSAV)- change of PSA over time
PSA kinetics- standardizing levels in relation to the size of the
prostate
PSA isoforms- free vs protein-bound molecular forms of PSA

1. PSA KINETICS
o PSAV refers to the rate of change of serum PSA
o its inverse, PSA doubling time (PSADT) indicates the amount of time
required for the PSA to double.
o men with prostate cancer have a more rapidly rising serum PSA in the
years before diagnosis than do men without prostate cancer.
Patients whose serum PSA increases by 0.75 ng/mL per year appear to be at an
increased risk of harboring cancer.
An elevated PSAV should be considered significant only when several serum PSA
assays are carried out by the same laboratory over a period of at least 18 months.
Very rapid PSA increases may be indicative of prostatitis (symptomatic or
otherwise) rather than cancer.

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2. PSA DENSITY
The ratio of PSA to gland volume is termed the PSA density
PSA levels are elevated on average approximately 0.12 ng/mL per gram of
BPH tissue.
prostate biopsy only if the PSA density exceeds 0.1 or 0.15.
The positive predictive value of PSA density is slightly higher than the use of
a PSA level >4 ng/mL in several series (3040% vs 2030%).
Major problem with PSA doubling (PSAD) is that it still requires TRUS,
which, while a lower risk procedure than biopsy, is still invasive and
uncomfortable.
PSAD may be most useful in settings in which the prostate volume is already
known

PROBLEMS WITH THIS APPROACH

epithelialstromal ratios vary from gland to gland and only the
epithelium produces PSA.
errors in calculating prostatic volume based on TRUS may approach
25%.

3. MOLECULAR FORMS OF PSA

Approximately 90% of the serum PSA is bound to 1-antichymotrypsin
(ACT), and lesser amounts are free or are bound to 2-macroglobulins.
PSA bound ACT may have three of its five epitopes masked.
A large multicentre study has reported that in men with a normal DRE and
a total PSA level between 4 and 10 ng/mL, a 25% free PSA cutoff would
detect 95% of cancers while avoiding 20% of unnecessary biopsies.
The cancers associated with >25% free PSA were more prevalent in older
patients and generally were less threatening in terms of tumor grade and
volume.
A serum panel adding free PSA, intact PSA, and hK2 to total PSA has been
shown to improve predictive accuracy for prostate cancer diagnosis among
men with a PSA >3.

4. PCA3
Prostate cancer antigen 3 (PCA3) is a noncoding, prostate-specific mRNA,
which is overexpressed in the majority of prostate cancers, with a median
66-fold upregulation compared with adjacent noncancer tissue.
PCA3 predicts the presence of cancer in a biopsy setting with an accuracy
of 74.6%.

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 PCA3 may be particularly useful in the evaluation of men with a negative
prior biopsy and a rising PSA.

Corpuz, Dalit, De Vera, Dela Cruz, De Omampo, Guevarra, Gurion, Iguid