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Objective To calculate the prevalence of renal cell carcinoma (RCC), upper urinary tract urothelial carcinoma (UT-UC), and lower urinary tract urothelial carcinoma (LT-UC) in patients with gross asymptomatic microhematuria (AMH) and symptomatic microhematuria (SMH). Patients and Methods This study was a population-based retrospective descriptive study. The study was approved by both the Mayo Clinic Institutional Review Board and the Olmsted Medical Center Institutional Review Board, and the population used was Olmsted County residents. A total of 4453 patients who presented with an initial episode of hematuria from January 1, 2000, through December 30, 2010, were included. Of the 4453 patients (median age, 58 years; interquartile range, 44.6-73.3 years), 1487 (33.4%) had gross hematuria, 2305 (51.8%) had AMH, and 661 (14.8%) had SMH. Results In the 1487 patients with gross hematuria, the prevalence of RCC, UT-UC, and LT-UC was 1.3%, 0.8%, and 9.0%, respectively. In the 2305 patients with AMH, the prevalence of RCC, UT-UC, and LT-UC was 0.2%, 0.3%, and 1.6%, respectively. In the 661 patients with SMH, the prevalence of RCC, UT-UC, and LT-UC was 0.6%, 0.2%, and 0.3%, respectively. Age was the most relevant risk factor for any hematuria type. Conclusion This unique cohort study reported that the prevalence of RCC or UC in patients with AMH and SMH was low, especially in the young cohort, and a large number of intense work-ups, such as cystoscopy and computed tomography urography, currently conducted could be omitted if stratified by hematuria type and age.

Purpose To reduce slice-to-slice motion effects in multislice T 2 -weighted fast-spin-echo ( T 2 FSE) imaging, manifest as "scalloping" in reformats, by modification of the acquisition strategy and to show applicability in prostate MRI. Methods T 2 FSE images of contiguous or overlapping slices are typically acquired using multiple passes in which each pass is comprised of multiple slices with slice-to-slice gaps. Combination of slices from all passes provides the desired sampling. For enhancement of through-plane resolution with super resolution or for reformatting into other orientations, subtle ≈1 mm motion between passes can cause objectionable "scalloping" artifact. Here we address this by subdivision of each pass into multiple segments. Interleaving of segments from the multiple passes causes all slices to be acquired over substantially the same time, reducing pass-to-pass motion effects. This was implemented in acquiring 78 overlapped T 2 FSE axial slices and studied in phantoms and in 14 prostate MRI patients. Super-resolution axial images and sagittal reformats from the original and new segmented acquisitions were evaluated by 3 uroradiologists. Results For all criteria of sagittal reformats, the segmented acquisition was statistically superior to the original. For all sharpness criteria of axial images, although the trend preferred the original acquisition, the difference was not significant. For artifact in axial images, the segmented acquisition was significantly superior. Conclusions For prostate MRI the new segmented acquisition significantly reduces the scalloping motion artifact that can be present in reformats due to long time lags between the acquisition of adjacent or overlapped slices while retaining image sharpness in the acquired axial slices.

Our goal was to evaluate the long-term prognostic value of magnetic resonance imaging of the prostatectomy bed in patients with biochemical recurrence after radical prostatectomy for prostate cancer.Men with biochemical recurrence after radical prostatectomy who were studied by prostatectomy bed magnetic resonance imaging for suspected local recurrence were retrospectively evaluated. Locally recurrent tumors were noted and measured from imaging reports. Patients with nodal/bone lesions at the time of imaging were excluded. Kaplan-Meier and Cox regression analyses were used to assess systemic progression-free and prostate cancer-specific survival.A total of 896 men were enrolled and the imaging positive and negative groups for local recurrent tumor consisted of 441 and 455 men, respectively. On univariate analysis, preoperative prostate specific antigen (p=0.02), clinical tumor stage (p=0.006), pathological Gleason score from prostatectomy (p=0.02), subsequent salvage radiotherapy (p0.001), biochemical recurrence to magnetic resonance imaging time interval (p0.001), age at magnetic resonance imaging (p=0.047) and prostate specific antigen at magnetic resonance imaging (p0.001) were significantly different between magnetic resonance imaging positive and negative groups. Patients with negative magnetic resonance imaging results had worse systemic progression-free survival rates (p=0.025) and better prostate cancer-specific survival (p=0.016) than those with recurrence. Larger lesion size significantly increased risk of prostate cancer death (hazard ratio: 1.07; p0.001). On multivariable analysis, pathological Gleason scores ≥7 were independent prognostic factors of systemic progression (p0.05).Prostatectomy bed magnetic resonance imaging provides long-term prognostic information for the evaluation of patients with biochemical recurrence after prostatectomy. Post-prostatectomy patients with recurrent lesions on imaging had longer progression-free survival but shorter prostate cancer-specific survival compared to those without lesions. Additionally, those with larger lesions were associated with poorer cancer-specific survival.

The purpose of this study is to report the patient safety and image quality of 1.5-T multiparametric MRI of the prostate in patients with cardiac implantable electronic devices (CIEDs).In this retrospective study, a database was searched to identify prostate multiparametric 1.5-T MRI examinations performed with endorectal coils for patients with CIEDs from 2012 to 2016 (study group) and matched patients without CIEDs (control group). Clinical safety in the study group was reviewed. The specific absorption rate (SAR) and signal-to-noise ratio (SNR) were measured in both groups. Imaging quality and artifact on T2-weighted images, DW images, and dynamic contrast-enhanced images were rated on a 5-point scale by two independent readers.The study group consisted of total 28 multiparametric MRI examinations in 25 patients. There were no serious device-related adverse effects observed (0/28; 0%), and the estimated whole-body SAR in the study group was never greater than 1.5 W/kg. The SNR values tended to be lower in the study group than in the control group. However, overall perceived image preferences and influences of artifacts on image quality for the study group were not significantly different from those for the control group (p0.05), which were rated above average (rating 3) by both readers 1 and 2.Multiparametric 1.5-T MRI examination of the prostate can be safely performed in selected patients with CIEDs under controlled conditions with applicable image quality while maintaining a SAR less than 1.5 W/kg.

Purpose The goal of this work is to demonstrate 1 mm through-plane resolution in multislice T2SE MRI using k Z -space processing of overlapping slices and show applicability in prostate MRI. Methods Multiple overlapped slices are acquired and Fourier transformed in the slice-select direction. The slice profile is incorporated into a Tikhonov-regularized reconstruction. Through-plane resolution is tested in a resolution phantom. An anthropomorphic prostate phantom is used to study the SNR, and results are compared with theoretical prediction. The proposed method is tested in 16 patients indicated for clinical prostate MRI who gave written informed consent as overseen by our IRB. The "proposed" vs. "reference" multislice images are compared using multiple evaluation criteria for through-plane resolution. Results The modulation transfer function (MTF) plots of the resolution phantom show good modulation at frequency 0.5 lp/mm, demonstrating 1 mm through-plane resolution restoration. The SNR measurements experimentally match the theoretically predicted values. The radiological evaluation shows that the proposed method is superior to the reference method for five criteria of sharpness but inferior with respect to artifacts. Conclusions In conjunction with overlapped slices a k Z -space-based reconstruction approach can be used to improve through-plane resolution in multislice T2SE MRI. 1 mm resolution is demonstrated from 3.2 mm thick slices. The in vivo results from prostate MRI show improved sharpness when compared to the standard multislice method.

The aim of this study was to clarify the radiologic and clinical characteristics of multiple unilateral subcapsular cortical hemorrhagic cystic disease of the kidney. Fourteen patients with unique and characteristic multiple hemorrhagic subcapsular cortical cysts of the kidney, not categorized in any existing renal cystic diseases, were retrospectively reviewed. The clinical information including age, sex, symptom, family history of renal or renal cystic disease, and laboratory data were collected. CT and MRI findings including distribution, number and size of cysts, and CT attenuation and signal intensity on T1- and T2-weighted MRI of cysts were analyzed. All patients except one were young and none had a family history of renal or renal cystic disease. Common clinical symptoms were flank or abdominal pain and hematuria. In all cases, only the left kidney was involved at initial presentation. Cysts were small (median cyst size, 4–15 mm), numerous, and distributed mainly along the subcapsular cortex of the kidney. Cysts were hyper-attenuated on unenhanced CT, extremely hypointense on T2-weighted MRI, and mildly hyperintense on T1-weighted MRI. All patients except one had normal renal function. Imaging follow-up revealed stable or mildly progressive disease in seven patients. Two patients developed several hemorrhagic subcapsular cortical cysts in the right kidney at follow-up. Three of five patients with a renal pathology specimen showed concurrent IgA nephropathy. We have identified a unique renal cystic disease with multiple unilateral subcapsular cortical hemorrhagic cystic disease of the kidney that has a characteristic manifestation both radiologically and clinically. • Multiple unilateral subcapsular cortical hemorrhagic cystic disease of the kidney is a unique non-familial renal cystic disease with a characteristic manifestation both radiologically and clinically. • Most cases of multiple unilateral subcapsular cortical hemorrhagic cystic disease of the kidney are stable or slowly progressive, and do not require invasive intervention.

An earlier incorrect version appeared online. This article was corrected on December 14, 2018.

International audience; Background and objectives The prevalence of autosomal dominant polycystic kidney disease (ADPKD) remains controversial. Incidence rates in Olmsted County, Minnesota, during 1935–1980 were previously reported. The current work extends this study to 2016. Design, setting, participants, & measurements The Rochester Epidemiology Project and radiology databases of Mayo Clinic and Olmsted Medical Center (healthcare providers for Olmsted County) were searched to identify all subjects meeting diagnostic criteria for definite, likely, and possible ADPKD. Annual incidence rates were calculated using incident cases during 1980–2016 as numerator and age- and sex-specific estimates of the population of Olmsted County as denominator. Point prevalence was calculated using prevalence cases as numerator and age- and sex-specific estimates of the population of Olmsted County on January 1, 2010 as denominator. Survival curves from the time of diagnosis were compared with expected survival of the Minnesota population. Results The age- and sex-adjusted annual incidence of definite and likely ADPKD diagnosis during 1980–2016 was 3.06 (95% CI, 2.52 to 3.60) per 100,000 person-years, which is 2.2 times higher than that previously reported for 1935–1980 (1.38 per 100,000 person-years). The point prevalence of definite or likely ADPKD on January 1, 2010 was 68 (95% CI, 53.90 to 82.13) per 100,000 population. Much higher incidence rates and point prevalence were obtained when possible ADPKD cases were included. Contrary to the previous Olmsted County study, patient survival in this study was not different from that in the general population. Conclusions The point prevalence of definite and likely ADPKD observed in this study is higher than those reported in the literature, but lower than genetic prevalence based on estimates of disease expectancy or on analysis of large population-sequencing databases.

OBJECTIVES To evaluate the timing and distribution of first renal cell carcinoma metastasis after nephrectomy stratified by nodal status. METHODS We evaluated patients treated with nephrectomy for sporadic, unilateral renal cell carcinoma between 1970 and 2011 who subsequently developed distant metastasis to three or fewer sites. Site-specific metastases-free 2-year survival rates were estimated using the Kaplan-Meier method. Associations of nodal status with time to metastasis were evaluated using multivariable Cox regression models. RESULTS A total of 1049 patients met the inclusion criteria (135 pN1, 914 pN0/x patients). The median time to identification of first distant metastasis for pN1 patients was 0.4 years (interquartile range 0.2-1.1 years) versus 2.2 years (interquartile range 0.6-6.0 years) in pN0/x patients. The most common site of metastasis was to the lung, but this occurred earlier in pN1 patients (median 0.3 years vs 2.0 years). pN1 was associated with significantly lower site-specific 2-year metastases-free survival when compared with pN0/x for lung (37% vs 70%, P

Deep learning techniques are being rapidly applied to medical imaging tasks-from organ and lesion segmentation to tissue and tumor classification. These techniques are becoming the leading algorithmic approaches to solve inherently difficult image processing tasks. Currently, the most critical requirement for successful implementation lies in the need for relatively large datasets that can be used for training the deep learning networks. Based on our initial studies of MR imaging examinations of the kidneys of patients affected by polycystic kidney disease (PKD), we have generated a unique database of imaging data and corresponding reference standard segmentations of polycystic kidneys. In the study of PKD, segmentation of the kidneys is needed in order to measure total kidney volume (TKV). Automated methods to segment the kidneys and measure TKV are needed to increase measurement throughput and alleviate the inherent variability of human-derived measurements. We hypothesize that deep learning techniques can be leveraged to perform fast, accurate, reproducible, and fully automated segmentation of polycystic kidneys. Here, we describe a fully automated approach for segmenting PKD kidneys within MR images that simulates a multi-observer approach in order to create an accurate and robust method for the task of segmentation and computation of TKV for PKD patients. A total of 2000 cases were used for training and validation, and 400 cases were used for testing. The multi-observer ensemble method had mean ± SD percent volume difference of 0.68 ± 2.2% compared with the reference standard segmentations. The complete framework performs fully automated segmentation at a level comparable with interobserver variability and could be considered as a replacement for the task of segmentation of PKD kidneys by a human.

Purpose: Limited duration cytoreductive neoadjuvant hormonal therapy (NHT) is used prior to definitive radiotherapeutic management of prostate cancer to decrease prostate volume. The purpose of this study is to examine the effect of NHT on prostate volume before permanent prostate brachytherapy (PPB), and determine associated predictive factors. Material and methods : Between June 1998 and April 2012, a total of 1,110 patients underwent PPB and 207 patients underwent NHT. Of these, 189 (91.3%) underwent detailed planimetric transrectal ultrasound before and after NHT prior to PPB. Regression analysis was used to assess predictors of absolute and percentage change in prostate volume after NHT. Results: The median duration of NHT was 4.9 months with inter quartile range (IQR), 4.2-6.6 months. Prostate-specific antigen (PSA) reduced by a median of 97% following NHT. The mean prostate volume before NHT was 62.5 ± 22.1 cm 3 (IQR: 46-76 cm 3 ), and after NHT, it was 37.0 ± 14.5 cm 3 (IQR: 29-47 cm 3 ). The mean prostate volume reduction was 23.4 cm 3 (35.9%). Absolute prostate volume reduction was positively correlated with initial volume and inversely correlated with T-stage, Gleason score, and NCCN risk group. In multivariate regression analyses, initial prostate volume (p < 0.001) remained as a significant predictor of absolute and percent prostate volume reduction. Total androgen suppression was associated with greater percent prostate volume reduction than luteinizing hormone releasing hormone agonist (LHRHa) alone (p = 0.001). Conclusions : Prostate volume decreased by approximately one third after 4.9 months of NHT, with total androgen suppression found to be more efficacious in maximizing cytoreduction than LHRHa alone. Initial prostate volume is the greatest predictor for prostate volume reduction.

A number of inherited renal diseases present with renal cysts and often lead to end-stage renal disease. With recent advances in genetics, increasing number of genes and mutations have been associated with cystic renal diseases. Although genetic testing can provide a definite diagnosis, it is often reserved for equivocal cases or for ongoing investigational research. Therefore, imaging findings are essential in the routine diagnosis, follow-up, and detection of complications in patients with inherited cystic renal diseases. In this article, the most recent classification, genetic analysis, clinical presentations, and imaging findings of inherited cystic renal diseases will be discussed.

Nonanaphylactic noncardiogenic pulmonary edema leading to cardiorespiratory arrest related to the magnetic resonance imaging contrast agent gadobutrol has rarely been reported in the literature. Rarer is the association of hypokalemia with acidosis. We report 2 patients who had severe pulmonary edema associated with the use of gadobutrol contrast in the absence of other inciting agents or events. These cases were unique not only for their rare and severe presentations but also because they exemplified the increasing role of extracorporeal membrane oxygenation in resuscitation. Emergency extracorporeal membrane oxygenation resuscitation can be rapidly initiated and successful in the setting of a well-organized workflow, and it is a viable alternative and helps improve patient outcome in cases refractory to conventional resuscitative measures.

Introduction Nephron sparing surgery may be challenging in cases of complex or aberrant renal anatomy. 3-Dimensional printing technology has allowed the creation of 3-dimensional models that can aid in preoperative surgical planning and simulation. We describe the construction of personalized 3-dimensional kidney models, and present a series of patients with complex surgical anatomy to illustrate their use in surgical planning and performance of complex nephron sparing surgery. Methods Three patients with complex renal masses were identified. Contrast enhanced computerized tomography studies were used to create segmentation images based on separate scan phases, which were overlaid to create virtual 3-dimensional models. High-fidelity 3-dimensional physical models were then created using 3-dimensional printing technology. The 3-dimensional models were used as an aid in the surgical planning and performance of nephron sparing surgery. Results Three patients with complex renal anatomy presented with T1b or T2 renal masses. Two patients had absolute or relative indications for nephron sparing surgery and in 1 patient a benign mass was suspected on imaging. The 3-dimensional kidney models were constructed based on preoperative cross-sectional imaging to evaluate the feasibility of nephron sparing surgery and to simulate the surgical approach. All patients underwent successful nephron sparing surgery with negative surgical margins and preservation of renal function at followup. Conclusions We describe the creation of personalized 3-dimensional kidney models to facilitate the visualization of the renal mass and its relationship with surrounding structures, the identification of renal and tumor vasculature, and the evaluation of aberrant anatomy. These 3-dimensional models represent a valuable tool for preoperative planning and simulation in cases with complex anatomical considerations.

The goal of this work is to demonstrate 1 mm through-plane resolution in multislice T2SE MRI using kMultiple overlapped slices are acquired and Fourier transformed in the slice-select direction. The slice profile is incorporated into a Tikhonov-regularized reconstruction. Through-plane resolution is tested in a resolution phantom. An anthropomorphic prostate phantom is used to study the SNR, and results are compared with theoretical prediction. The proposed method is tested in 16 patients indicated for clinical prostate MRI who gave written informed consent as overseen by our IRB. The "proposed" vs. "reference" multislice images are compared using multiple evaluation criteria for through-plane resolution.The modulation transfer function (MTF) plots of the resolution phantom show good modulation at frequency 0.5 lp/mm, demonstrating 1 mm through-plane resolution restoration. The SNR measurements experimentally match the theoretically predicted values. The radiological evaluation shows that the proposed method is superior to the reference method for five criteria of sharpness but inferior with respect to artifacts.In conjunction with overlapped slices a k

Purpose Noninvasive imaging techniques that quantify renal tissue composition are needed to more accurately ascertain prognosis and monitor disease progression in polycystic kidney disease (PKD). Given the success of magnetization transfer (MT) imaging to characterize various tissue remodeling pathologies, it was tested on a murine model of autosomal dominant PKD. Methods C57Bl/6 Pkd1 R3277C mice at 9, 12, and 15 months were imaged with a 16.4T MR imaging system. Images were acquired without and with RF saturation in order to calculate MT ratio (MTR) maps. Following imaging, the mice were euthanized and kidney sections were analyzed for cystic and fibrotic indices, which were compared with statistical parameters of the MTR maps. Results The MTR-derived mean, median, 25th percentile, skewness, and kurtosis were all closely related to indices of renal pathology, including kidney weight/body weight, cystic index, and percent of remaining parenchyma. The correlation between MTR and histology-derived cystic and fibrotic changes was R2 = 0.84 and R2 = 0.70, respectively. Conclusion MT imaging provides a new, noninvasive means of measuring tissue remodeling PKD changes and may be better suited for characterizing renal impairment compared with conventional MR techniques. Magn Reson Med, 2015.

PURPOSE: To evaluate the reproducibility and utility of quantitative magnetic resonance imaging (MRI) sequences for the assessment of kidneys in young adults with normal renal function (eGFR ranged from 90 to 130mL/min/1.73m(2)) and patients with early renal disease (autosomal dominant polycystic kidney disease). MATERIALS AND METHODS: This prospective case-control study was performed on ten normal young adults (18–30 years old) and ten age and sex matched patients with early renal parenchymal disease (Autosomal Dominant Polycystic Kidney Disease). All subjects underwent a comprehensive kidney MRI protocol, including qualitative imaging: T1w, T2w, FIESTA, and quantitative imaging: 2D cine phase contrast of the renal arteries, and parenchymal diffusion weighted imaging (DWI), magnetization transfer imaging (MTI), blood oxygen level dependent (BOLD) imaging, and magnetic resonance elastography (MRE). The normal controls were imaged on two separate occasions ≥24 hours apart (range 24 to 210hrs) to assess reproducibility of the measurements. RESULTS: Quantitative MR imaging sequences were found to be reproducible. The mean±SD absolute percent difference between quantitative parameters measured ≥24 hours apart were: MTI-derived ratio = 4.5±3.6%, DWI-derived apparent diffusion coefficient (ADC) = 6.5±3.4%, BOLD-derived R2* = 7.4±5.9%, and MRE-derived tissue stiffness = 7.6±3.3%. Compared with controls, the ADPKD patient’s non-cystic renal parenchyma (NCRP) had statistically significant differences with regard to quantitative parenchymal measures: lower MTI percent ratios (16.3±4.4 vs. 23.8±1.2, p

The purpose of our study was to examine the safety and diagnostic utility of transgluteal CT-guided prostate biopsy for prostate sampling in patients without rectal access.Seventy-three biopsies were performed in 65 patients over a 13-year period (2002-2015). Mean prostate-specific antigen (PSA) at biopsy was 7.8 ng/mL (range 0.37-31.5). Electronic medical records were reviewed for procedural details and complications. Mean PSA and number of cores in malignant and benign cohorts were compared with Student's t test.Technical success rate was 97.3% (71/73; mean cores 8, range 3-28). Of these, 43.6% (31/71) yielded malignancy (mean Gleason score 7, range 6-10) and 56.3% (40/71) yielded benign tissue. The only complication was an asymptomatic periprostatic hematoma (1/73; 1.4%). In 14 patients who underwent surgery, Gleason scores were concordant in 71.4% (10/14) and discordant in 28.6% (4/14; Gleason 6 on biopsy but Gleason 7 on surgical specimen). Mean effective radiation dose was 18.5 mSv (median 15.0, range 4.4-86.2). There was no significant difference in either mean PSA (p = 0.06) or number of core specimens (p = 0.33) between malignant and benign cohorts.CT-guided transgluteal prostate biopsy is highly safe and reliable for the detection of prostate cancer in men without rectal access.• Prostate cancer detection in men without rectal access is challenging. • CT-guided transgluteal prostate biopsy is safe and effective in these patients. • CT-guided biopsy may be particularly effective in diagnosing high-grade prostate cancer. • Unilateral CT-guided biopsy may be effective in patients with focal lesions. • The radiation exposure with this technique is acceptable.

Magnetic resonance imaging (MRI) examinations provide high-resolution information about the anatomic structure of the kidneys and are used to measure total kidney volume (TKV) in patients with Autosomal Dominant Polycystic Kidney Disease (ADPKD). Height-adjusted TKV (HtTKV) has become the gold-standard imaging biomarker for ADPKD progression at early stages of the disease when estimated glomerular filtration rate (eGFR) is still normal. However, HtTKV does not take advantage of the wealth of information provided by MRI. Here we tested whether image texture features provide additional insights into the ADPKD kidney that may be used as complementary information to existing biomarkers. A retrospective cohort of 122 patients from the Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease (CRISP) study was identified who had T2-weighted MRIs and eGFR values over 70 mL/min/1.73m 2 at the time of their baseline scan. We computed nine distinct image texture features for each patient. The ability of each feature to predict subsequent progression to CKD stage 3A, 3B, and 30% reduction in eGFR at eight-year follow-up was assessed. A multiple linear regression model was developed incorporating age, baseline eGFR, HtTKV, and three image texture features identified by stability feature selection (Entropy, Correlation, and Energy). Including texture in a multiple linear regression model (predicting percent change in eGFR) improved Pearson correlation coefficient from -0.51 (using age, eGFR, and HtTKV) to -0.70 (adding texture). Thus, texture analysis offers an approach to refine ADPKD prognosis and should be further explored for its utility in individualized clinical decision making and outcome prediction.

Hereditary forms of kidney carcinoma account for 5-8% of all malignant kidney neoplasms. The renal tumors are often multiple and bilateral and occur at an earlier age. Each of the hereditary kidney carcinoma syndromes is associated with specific gene mutations as well as a specific histologic type of kidney carcinoma. The presence of associated extrarenal manifestations may suggest a hereditary kidney cancer syndrome. Radiology is most commonly used to screen and manage patients with hereditary kidney cancer syndromes. This manuscript reviews the clinical and imaging findings of well-defined inherited kidney cancer syndromes including von Hippel-Lindau disease, Birt-Hogg-Dube syndrome, hereditary papillary renal carcinoma syndrome, hereditary leiomyomatosis and RCC syndrome, tuberous sclerosis complex, and Lynch syndrome.

Inflatable penile prostheses are a common treatment for erectile dysfunction that is unresponsive to less-invasive measures. Complications can arise at the time of the placement of the prosthesis or at a later date. Complications may be related to infection and/or mechanical failure of one or more of the prosthesis components including cylinder, reservoir, pump, and tubing. Mechanical failure includes kinking, migration, and aneurysmal dilation of the cylinder, erosion of the tunica albuginea of the corpora cavernosum by the cylinder, disconnection of the tubing, and migration of the reservoir. MRI of the entire components with the cylinders in both flaccid and inflated states is the best imaging modality available to image patients with suspected implant complications.

Background. We showed in a randomized double-blinded placebo-controlled clinical trial that octreotide long-acting repeatable depot.® (OctLAR ® ) for 12 months reduces kidney and liver growth in autosomal dominant polycystic kidney patients with severe polycystic liver disease (PLD) and liver growth in patients with severe isolated PLD. We have now completed an open-label extension for one additional year to assess safety and clinical benefits of continued use of OctLAR for 2 years (O→O) and examined drug effect in the placebo group who crossed over to OctLAR in Year 2 (P→O). Methods. The primary end point was change in total liver volume (TLV) measured by magnetic resonance imaging (MRI); secondary end points were changes in total kidney volume (TKV) measured by MRI, glomerular filtration rate (GFR), quality of life (QOL), safety, vital signs and laboratory parameters. Results. Forty-one of 42 patients received OctLAR (n = 28) or placebo (n = 14) in Year 1 and received OctLAR in Year 2 (maximum dose 40 mg). Patients originally randomized to placebo (P→O) showed substantial reduction in TLV after treatment with OctLAR in Year 2 (Δ% −7.66 ± 9.69%, P = 0.011). The initial reduction of TLV in the OctLAR group (O→O) was maintained for 2 years (Δ% −5.96 ± 8.90%), although did not change significantly during Year 2 (Δ% −0.77 ± 6.82%). OctLAR inhibited renal enlargement during Year 1 (Δ% +0.42 ± 7.61%) in the (O→O) group and during Year 2 (Δ% −0.41 ± 9.45%) in the (P→O) group, but not throughout Year 2 (Δ% +6.49 ± 7.08%) in the (O→O) group. Using pooled analyses of all individuals who received OctLAR for 12 months, i.e. in Year 1 for O→O patients and Year 2 for P→O patients, average reduction in TLV was −6.08 ± 7.58% (P = 0.001) compared to net growth of 0.9 ± 8.35% in the original placebo group. OctLAR-treated individuals continued to experience improvements in QOL in Year 2, although overall physical and mental improvements were not significant during Year 2 compared to Year 1. Changes in GFR were similar in both groups. Conclusion. Over 2 years, OctLAR significantly reduced the rate of increase in TLV and possibly the rate of increase in TKV.

Study Type – Diagnostic (case series) Level of Evidence 4 What's known on the subject? and What does the study add? It is known that magnetic resonance imaging (MRI) is safe and effective for imaging patients with inflatable penile prostheses (IPPs). Previous series have reported results of MRI for imaging series of patients with IPPs. The impact on management in particular with regard to salvage procedures is not well defined. This study represents the largest known experience with MRI evaluation of IPPs. This also provides an algorithm that assists with decisions regarding utilization of MRI and treatment planning based on results. OBJECTIVE • In some patients who undergo placement of an inflatable penile prosthesis (IPP) the device may function inadequately. We describe the use of magnetic resonance imaging (MRI) for anatomical localization and detection of prosthesis malrotation, angulation, displacement and erosion in IPPs with equivocal clinical examination. PATIENTS AND METHODS • We prospectively performed MRI by a defined protocol including T1-weighted imaging, and transaxial, sagittal and coronal fat-saturated fast spin-echo T2-weighted imaging in both deflated and inflated states to evaluate patients seen at our referral centre for IPP-related complaints. • We retrospectively reviewed 32 such MRI studies performed as a supplement to clinical examination between 2000 and 2008. RESULTS • Of 32 cases, 75% (24/32) underwent surgical intervention. Of these, 45% (11/24) underwent device salvage procedures including cylinder revision in 33% (8/24), cylinder replacement in 8% (2/24) and pump replacement in 4% (1/24). • MRI was most useful for determination of surgical approach in those with abnormal physical examination, and for justification of either surgical or expectant management in those with indeterminate physical examination. CONCLUSIONS • MRI is safe and effective for imaging genitourinary prostheses. • We found MRI to be a valuable adjunct for evaluation of IPP-related complaints when clinical examination is equivocal as it detected a variety of prosthetic and corporal abnormalities and impacted management decisions regarding observation, replacement or device salvage procedures. • We provide technique, results and an algorithm that can be beneficial in this complex subset of patients.

The rapidly changing technological and business environment in which scientific journals are published will necessitate ongoing reassessment of operations, goals, and priorities. In this white paper, the ACR Task Force on Print Media in Radiology reviews the history and role of print media in radiology; discusses current and anticipated societal, technological, and financial challenges; and explores a variety of strategies to help ensure the relevance of professional society publishing in the future.

Summary Background and objectives The Consortium for Radiologic Imaging Studies of Polycystic Kidney Disease (CRISP) was created to identify markers of disease progression in patients with autosomal dominant polycystic kidney disease (ADPKD). Design, setting, participants, & measurements Linear mixed models were utilized to model effects of baseline parameters on changes in natural-log (ln)-transformed total kidney volume (TKV) and iothalamate clearance (GFR) across time in CRISP participants (creatinine clearance at entry >70 ml/min). Stepwise selection was used to obtain a final main effect model. Results TKV increased from year to year, whereas GFR uncorrected for body surface area (BSA) decreased only at year 6. Higher lnTKV and urine sodium excretion (U Na V), lower serum HDL-cholesterol, and younger age at baseline associated with greater lnTKV growth from baseline to year 3 and to year 6. Higher lnTKV at baseline associated with greater GFR decline from year 1 to year 3 and to year 6. Higher BSA and 24-hour urine osmolality at baseline associated with greater GFR decline from year 1 to year 6. Higher U Na V and lower serum HDL-cholesterol at baseline associated with greater GFR decline from year 1 to year 6 by univariate analysis only. Associations seen during year 1 to year 6 (not seen during year 1 to year 3) reflect the time lag between structural and functional disease progression. Conclusions Serum HDL-cholesterol, U Na V, and 24-hour urine osmolality likely affect ADPKD progression. To what extent their modification may influence the clinical course of ADPKD remains to be determined.

This study evaluates reliability of current technology for measurement of renal arterial blood flow by breath-held velocity-encoded MRI. Overall accuracy was determined by comparing MRI measurements with known flow in controlled-flow-loop phantom studies. Measurements using prospective and retrospective gating methods were compared in phantom studies with pulsatile flow, not revealing significant differences. Phantom study results showed good accuracy, with deviations from true flow consistently below 13% for vessel diameters 3mm and above. Reproducibility in human subjects was evaluated by repeated studies in six healthy control subjects, comparing immediate repetition of the scan, repetition of the scan plane scouting, and week-to-week variation in repeated studies. The standard deviation in the 4-week protocol of repeated in vivo measurements of single-kidney renal flow in normal subjects was 59.7 mL/min, corresponding with an average coefficient of variation of 10.55%. Comparison of renal arterial blood flow reproducibility with and without gadolinium contrast showed no significant differences in mean or standard deviation. A breakdown among error components showed corresponding marginal standard deviations (coefficients of variation) 23.8 mL/min (4.21%) for immediate repetition of the breath-held flow scan, 39.13 mL/min (6.90%) for repeated plane scouting, and 40.76 mL/min (7.20%) for weekly fluctuations in renal blood flow.

The objective of our study was to compare the spatial resolution and effective dose from 64-MDCT with several published CT urography protocols.A phantom containing 1-, 2-, or 4-mm cylindric channels to simulate ureters with 0.25- to 3-mm plugs to simulate ureteral filling defects or ureteral diverticula was imaged using eight helical CT urography protocols. Computed radiography (CR) was also performed. Coronal maximum-intensity-projection images were created and, with the CR image, were evaluated independently by two genitourinary radiologists. Spatial resolution was evaluated by scoring each abnormality as present, visible; or as absent, not visible. Effective dose estimates for 11 CT urography protocols, including the radiographs obtained in the CT urography protocol, were calculated using published Monte Carlo organ dose coefficients.All ureteral abnormalities detected on CR were detected on the highest-spatial-resolution reconstruction using the evaluated 64-MDCT system. The smallest filling defect identified by both was 0.25 mm. Three 0.25-mm filling defects were not detected using the evaluated 16-MDCT system. The 4-MDCT system protocols showed the poorest performance. The range of effective doses for the evaluated CT urography protocols was 20.1-66.3 mSv. The number of phases, anatomic coverage per phase, and scanning parameters all contributed to this variation in dose.The evaluated 64-MDCT system showed detection accuracy identical to that of CR. Limiting anatomic coverage for specific phases and combining phases can reduce dose for multiphase protocols by up to a factor of 2 relative to early (circa 2000) 4-MDCT.

The key components of the MR urography protocol for suspected upper tract urothelial carcinoma are coronal T2-weighted hydrographic sequences without contrast agent and coronal gadolinium-enhanced T1-weighted 3D-spoiled gradient-recalled echo in nephrographic and pyelographic phases. Upper tract urothelial carcinomas can be categorized into papillary tumor, flat tumor, and infiltrative tumor based on the growth pattern and extent. Papillary lesions appear as small filling defects of soft tissue signal on T2-weighted hydrographic and T1-weighted pyelographic phase images. On nephrographic phase images, the lesions show homogeneous enhancement. A flat tumor appears as a segmental area of diffuse thickening and enhancement of the urinary tract wall on nephrographic phase images. Infiltrative tumor often appears as a large heterogeneously enhancing mass. MR urography is a promising alternative for CT urography in the evaluation of upper tract urothelial carcinoma, especially when the patient has a contraindication to iodinated contrast material.

Objective. The purpose of this study was to determine whether the clinical history and sonographic appearance of solid epididymal masses could aid in distinguishing benign and malignant disease. Methods. We retrospectively reviewed the medical records of all patients who had solid epididymal masses evaluated by scrotal sonography at our institution between 1996 and 2004. We evaluated multiple clinical and sonographic variables, including lesion size, location, echogenicity, color Doppler characteristics, and calcifications. Results. Of the 85 patients included in the study, 25 (29%) underwent surgical intervention, and 5 (6%) had malignant disease. A mass size of greater than 1.5 cm and the presence of color Doppler flow were statistically significant markers for malignancy (P < .05). Combining these 2 variables as a test for malignancy yielded sensitivity of 100%, specificity of 80%, a positive predictive value of 24%, and a negative predictive value of 100%. Conclusions. Most solid epididymal masses (94%) are benign. A size of greater than 1.5 cm and the presence of color Doppler flow may help identify possible malignant masses.

To retrospectively evaluate the detection of small (2-cm) urothelial tumors by using gadolinium-enhanced three-dimensional (3D) spoiled gradient-recalled echo (GRE) magnetic resonance (MR) urography.This HIPAA-compliant study received institutional review board approval. All patients included had previously consented to the use of their medical records for research purposes. Eleven of 110 patients (10 men, one woman; mean age, 73.5 years) who underwent MR urography were ultimately identified to have 23 upper-tract urothelial carcinomas smaller than 2 cm or carcinoma in situ. Breath-hold coronal T2-weighted single-shot fast spin-echo and breath-hold coronal 3D T1-weighted spoiled GRE images with fat suppression during nephrographic and excretory phases after intravenous injection of gadolinium-based contrast material were obtained in all patients with a 1.5-T imager. Two radiologists reviewed the MR images in consensus for the presence of tumors. Lesion detectability was compared between each sequence by using the McNemar test.Of 23 tumors, 17 (74%) were detected by using at least one sequence, eight (35%) were detected with T2-weighted imaging, 15 (65%) were detected on nephrographic phase images, and 15 (65%) were detected on excretory phase images. Two lesions each were detected only on either nephrographic or excretory phase images. Detectability was significantly higher on nephrographic and excretory phase images compared with T2-weighted images (P.05).Gadolinium-enhanced 3D spoiled GRE MR urography helped detect 74% of small urothelial carcinomas. Nephrographic and excretory phase images are essential for helping detect small urothelial carcinomas.

Background and objectives: Autosomal dominant polycystic kidney disease (ADPKD) is a common hereditary disease with prominent connective tissue manifestations. A frequent occurrence of asymptomatic pericardial effusion has been observed in patients with ADPKD. Design, setting, participants, & measurements: Consecutive computed tomography scans from 60 patients with ADPKD (group 1), 100 patients without ADPKD and with serum creatinine concentration of ≥1.1 mg/dl (group 2), and 100 potential kidney donors (group 3) were retrospectively examined. Pericardial effusion was graded from 0 to 4 on the basis of the distance between the parietal and visceral pericardia at mid, mid-low, and low levels of the heart on transaxial computed tomography scan sections. Results: Twenty-one (35%) of 60 patients in group 1 were found to have pericardial effusion, compared with 9 (9%) and 4 (4%) patients in groups 2 and 3, respectively. Ten of the 21 patients with pericardial effusion in group 1 but none of the patients in groups 2 and 3 had moderate to high effusion scores. The presence and severity of pericardial effusion were not associated with age, renal dysfunction, or hypertension. All pericardial effusions were asymptomatic. Conclusions: Pericardial effusion occurs with an increased frequency in patients with ADPKD, possibly as a result of increased compliance of the parietal pericardium. Although frequently moderate to large, these effusions are generally well tolerated and clinically inconsequential.

Nonanaphylactic noncardiogenic pulmonary edema leading to cardiorespiratory arrest related to the magnetic resonance imaging contrast agent gadobutrol has rarely been reported in the literature. Rarer is the association of hypokalemia with acidosis. We report 2 patients who had severe pulmonary edema associated with the use of gadobutrol contrast in the absence of other inciting agents or events. These cases were unique not only for their rare and severe presentations but also because they exemplified the increasing role of extracorporeal membrane oxygenation in resuscitation. Emergency extracorporeal membrane oxygenation resuscitation can be rapidly initiated and successful in the setting of a well-organized workflow, and it is a viable alternative and helps improve patient outcome in cases refractory to conventional resuscitative measures.

Background To determine the effect of statins on renal hemodynamics in normal volunteers and those with autosomal dominant polycystic kidney disease either with mild or moderate renal dysfunction. Methods Thirty-two study subjects were enrolled in this study: 11 normal volunteers, 11 study subjects with autosomal dominant polycystic kidney disease (ADPKD) and mild kidney disease and 10 study subjects with ADPKD and moderate kidney disease. Subjects in each group received simvastatin 40 mg once daily for a period of 4 weeks. Renal blood flow was measured based on para-amino-hippurate (PAH) clearance and with the use of a magnetic resonance (MR) scanner at the beginning and following 4 weeks of therapy with statins. Results At the end of the study, except for the lipid profile, which was significantly lower in all groups, other laboratory results showed no change. Four weeks of therapy with simvastatin resulted in no change in serum creatinine, 24-h urinary protein, sodium, iothalamate clearance, PAH clearance or renal blood flow as measured by MRI or based on PAH clearance. Conclusions Four weeks of therapy with simvastatin did not change renal blood flow in the study subjects with ADPKD with mild-to-moderate renal dysfunction or in healthy volunteers. Clinical trial registration number NCT02511418.

Background Renal imaging examinations provide high-resolution information about the anatomic structure of the kidneys and are used to measure total kidney volume (TKV) in autosomal dominant polycystic kidney disease (ADPKD) patients. TKV has become the gold-standard image biomarker for ADPKD progression at early stages of the disease and is used in clinical trials to characterize treatment efficacy. Automated methods to segment the kidneys and measure TKV are desirable because of the long time requirement for manual approaches such as stereology or planimetry tracings. However, ADPKD kidney segmentation is complicated by a number of factors, including irregular kidney shapes and variable tissue signal at the kidney borders. Methods We describe an image processing approach that overcomes these problems by using a baseline segmentation initialization to provide automatic segmentation of follow-up scans obtained years apart. We validated our approach using 20 patients with complete baseline and follow-up T1-weighted magnetic resonance images. Both manual tracing and stereology were used to calculate TKV, with two observers performing manual tracings and one observer performing repeat tracings. Linear correlation and Bland-Altman analysis were performed to compare the different approaches. Results Our automated approach measured TKV at a level of accuracy (mean difference ± standard error = 0.99 ± 0.79%) on par with both intraobserver (0.77 ± 0.46%) and interobserver variability (1.34 ± 0.70%) of manual tracings. All approaches had excellent agreement and compared favorably with ground-truth manual tracing with interobserver, stereological and automated approaches having 95% confidence intervals ∼ ± 100 mL. Conclusions Our method enables fast, cost-effective and reproducible quantification of ADPKD progression that will facilitate and lower the costs of clinical trials in ADPKD and other disorders requiring accurate, longitudinal kidney quantification. In addition, it will hasten the routine use of TKV as a prognostic biomarker in ADPKD.

Data from serial renal magnetic resonance imaging of the Consortium of Radiologic Imaging Study of PKD (CRISP) autosomal dominant polycystic kidney disease (PKD) population showed that cystic expansion occurs at a consistent rate per individual, although it is heterogeneous in the population, and that larger kidneys are associated with more rapid disease progression. The significance of gene type to disease progression is analyzed in this study of the CRISP cohort. Gene type was determined in 183 families (219 cases); 156 (85.2%) had PKD1, and 27 (14.8%) had PKD2. PKD1 kidneys were significantly larger, but the rate of cystic growth (PKD1 5.68%/yr; PKD2 4.82%/yr) was not different (P = 0.24). Cyst number increased with age, and more cysts were detected in PKD1 kidneys (P < 0.0001). PKD1 is more severe because more cysts develop earlier, not because they grow faster, implicating the disease gene in cyst initiation but not expansion. These insights will inform the development of targeted therapies in autosomal dominant PKD.

OBJECTIVE. The purpose of this article is to describe the appearance and location of the Essure permanent birth control device on sonography, CT, and MRI.CONCLUSION. The Essure device has a distinct appearance and typical location that allow it to be accurately identified on sonography, CT, and MRI scans.

The autosomal recessive form of polycystic kidney disease (ARPKD) is generally considered an infantile disorder with the typical presentation of greatly enlarged echogenic kidneys detected in utero or within the neonatal period, often resulting in neonatal demise. However, there is an increasing realization that survivors often thrive into adulthood with complications of the ductal plate malformation, manifesting as congenital hepatic fibrosis and Caroli disease, becoming prominent. Previous natural history studies have concentrated almost exclusively on the infantile presenting group. However, developments in understanding the genetic basis of ARPKD, through identification of the disease gene, PKHD1, have allowed exploration of the etiology in patients with ARPKD-like disease or congenital hepatic fibrosis presenting later in childhood or as adults. In the current study we retrospectively reviewed the clinical records, and where possible performed PKHD1 mutation screening, in patients diagnosed with ARPKD or congenital hepatic fibrosis at the Mayo Clinic, Rochester, MN, from 1961 to 2004. Of a total of 133 cases reviewed, 65 were considered to meet the diagnostic criteria with an average duration of follow-up of 8.6 +/- 6.4 years. Fifty-five cases had ARPKD and 10 had isolated congenital hepatic fibrosis with no or minimal renal involvement. The patients were analyzed as 3 groups categorized by the age at diagnosis;1 years (n = 22), 1-20 years (n = 23), and20 years (n = 20). The presenting feature in the neonates was typically associated with renal enlargement, but in the older groups, more often involved manifestations of liver disease, including hepatosplenomegaly, hypersplenism, variceal bleeding, and cholangitis. During follow-up, 22 patients had renal insufficiency and 8 developed end-stage renal disease (ESRD), most from the neonatal group. Liver disease was evident on follow-up in all diagnostic groups but particularly prevalent in those diagnosed later in life. A total of 12 patients died, 6 in the neonatal period, but 86% of patients were alive at 40 years of age. The likelihood of being alive without ESRD differed significantly between the diagnostic groups with 36%, 80%, and 88% survival in the 3 diagnostic groups, respectively, 20 years after the diagnosis. Considerable evidence of intrafamilial phenotype variability was observed. Mutation analysis was performed in 31 families and at least 1 mutation was detected in 25 (81%), with 76% of mutant alleles detected in those cases. Consistent with the relatively mild disease manifestations in this population, the majority of changes were missense (79%) and no case had 2 truncating changes. Mutations were detected in all diagnostic groups, indicating that congenital hepatic fibrosis with minimal kidney involvement can result from PKHD1 mutation. The finding of 6 cases with no detected mutations may represent missed mutations or possible evidence of genetic heterogeneity. The current study indicates a broadened spectrum for the ARPKD phenotype and that later presenting cases with predominant liver disease should be considered part of ARPKD.

Background: The accuracy and precision of ultrasonography (US) in assessing the severity of autosomal dominant polycystic kidney disease (ADPKD) is unknown. Methods: US and magnetic resonance imaging (MRI) were performed at baseline and 1 year on 230 subjects with ADPKD. Ellipsoid volume was calculated from US length, width, and depth, and sequential transverse images were used to measure total and cystic volume directly. These were compared with MRI measurements of kidney volume and cystic volume. Results: Variability between different sonographers ranged from 18% to 42%. Correlations between US and MRI volume were 0.88 and 0.89. The SD of the discrepancy from MRI ranged from 21% to 33% and was unrelated to kidney size or body mass. Kidney length was the most reproducible measurement, and its correlation with MRI volume was 0.84. All patients with an US volume less than 700 cm3 had an MRI volume less than 1,000 cm3, and all patients with an US volume greater than 1,700 cm3 had an MRI volume greater than 1,000 cm3. Increases in volume after 1 year were 12% ± 36% for the ellipsoid method, 6% ± 29% for the direct method, and 4.2% ± 7.2% for MRI. Correlation between US and MRI measurement of fractional cyst volume was 0.80. Conclusion: Sonographic measurement of kidney volume in patients with ADPKD is inaccurate and lacks the precision necessary to measure short-term disease progression. However, sonography can provide an estimate of kidney volume that reflects severity and prognosis in individual patients.