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Universidade Federal de So Paulo Escola Paulista de Medicina Departamento de Diagnstico por Imagem

Acurcia diagnstico da urotomografia na avaliao da hematria no adulto jovem


Especializando: Bruno Cheregati Pedrassa E4 Orientador: Viviane Vieira Francisco Data: 06/06/2012
Lokken RP; Sadow CA; Silverman SG. Diagnostic Yield of CT Urography in the Evaluation of Young Adults With Hematuria. AJR Am J Roentgenol. 2012; 198(3):60915

INTRODUO
Hematria achado comum em adultos jovens
-macroscpica: VPP para malignidade -microscpica: assintomtica, achado incidental

Estratgia de investigao controversa


American Urologic Association e ACR (hematria micro) Urografia excretora ou UroTC

Poucos achados, exposio radiao

OBJETIVOS
Determinar a acurcia da Urotomografia na avaliao de hematria em pacientes jovens, utilizando uma nica fase sem contraste

MATERIAIS E MTODOS
Retrospectivo, 2000-09 5400 TC

829 pacientes 40 anos

375 TC, indicao primria de hematria

MATERIAIS E MTODOS
- Macroscpica (n=142) - Microscpica (n= 181) - Indefinida (n=51) 1 etapa:
- 14 radiologistas, 1-12 anos exp: Verdadeiros e falsos-positivos
2 etapa: - 1 radiologista, 9 anos de exp, anlise cega dos resultados

MATERIAIS E MTODOS
2 etapa: Fontes de hematria, TC s/c - Exame sem achados, revistos por outro radiologista mais experiente (25anos)
TCMD: 4,16,64 e 128 canais 900 ml gua VO 250 ml SF + 10 mg Lasix EV Contraste EV, arterial, portal, tardia e equilbrio

RESULTADOS

RESULTADOS

140-year-old man who had episode of painless gross hematuria. A, Axial nephrographic phase image of CT urogram shows heterogeneously enhancing 6.4-cm right upper pole renal mass (arrow) suspicious for renal cell carcinoma. B, Renal mass was evident on unenhanced image. Patient was lost to follow-up before pathologic specimen was obtained

RESULTADOS

23-year-old woman with non-Hodgkin lymphoma who developed hematuria and abdominal pain while undergoing chemotherapy. CT urogram was performed, and oral contrast agent was administered for concurrent cancer staging. A, Axial nephrographic phase image shows hypoenhancing 3.4-cm right renal mass (arrow) suspicious for tumor. B, Renal mass was not detected on unenhanced image.

RESULTADOS

Fig. 340-year-old woman with multiple sclerosis, recurrent urinary tract infections,

and neurogenic bladder evaluated for microscopic hematuria. A and B, Coronal (A) and axial (B) images from excretory phase CT urogram show clubbed calyces (arrows) and sloughed papillae (arrowheads), consistent with severe papillary necrosis. C, Axial unenhanced phase image was insufficient to make diagnosis.

Fig. 433-year-old woman with gross hematuria. A and B, Axial (A) and sagittal (B) images from excretory phase of CT urogram show focal thickening (arrow, A) of anterior bladder wall at midline that was considered suspicious for urothelial neoplasm. In retrospect, sagittal image (B) shows that area of thickening (arrowhead) is on serosal surface and is contiguous with median umbilical ligament, finding typical of urachal insertion. C, Finding was not evident on unenhanced image. Cystoscopy was deferred, and patient has had no genitourinary problems with 2 years of clinical follow-up.

DISCUSSO
American Urologic Association, 2001:
- Urografia excretora ou UroTC - Cistoscopia - Urina I

ACR:
- UroTC (12-15 mSv) - Melhor avaliao de massas renais e alteraes extrarrenais

CONCLUSO
Cerca de 75% dos achados clnicos significantes eram devidos a clculo renal e ureteral 95% dos achados significantes: TC sem contraste Atualmente a Urotomografia: exame de escolha Estudo prope TC sem contraste, para avaliao inicial de hematria em adultos jovens

Critrio de avaliao de estudo (QUADAS)


1. O espectro de pacientes estudados foi significativo?
2. Os critrios de seleo foram claramente descritos?

Sim No N.A.
X
X

3. O padro referncia adequado ?


4. Intervalo de tempo suficientemente curto? 5. Todos os pacientes mesmo padro de referncia? 6. Cegamento para o teste avaliado

X
X X X

7. Cegamento para o padro referncia


8. Disponibilidade de dados clnicos 9. Resultados indeterminados/inconclusivos

X
X X

10. Excluses/desistncias
11. O estudo corresponde prtica clnica?

X
X