Citation Information :
Adityan R, Senthamil SC, Karthiga S, Prabhu C, Padhmini B. Triphasic Single Bolus and Biphasic Split Bolus Techniques in Computed Tomography Urography: A Pilot Study. 2021; 4 (1):2-9.
Aim and objective: Our study's objective is to examine the image quality, radiation dose, and scan time of the split bolus technique in computed tomography (CT) to evaluate urinary tract diseases.
Background: Computed tomography is one of the commonly preferred medical imaging modalities in diagnostic radiology for visualizing several diseases with higher resolution images. However, radiation dose reduction is one of the most crucial causes of a CT examination. Multidetector CT (MDCT) has updated several technical advancements of CT scanner for clinical purposes. The excretory system's radiological investigation is called urography, which is done in conventional radiography in the old days. Urolithiasis is considered a common disease affecting 12% of the global population in their lives.
Materials and methods: In our study, 10 patients underwent a split bolus technique for CT urography (CTU) examination at the Mahatma Gandhi Medical College and Research Institute, Puducherry. Among the 10 patients, 6 patients are adult male, 1 patient is a pediatric male, and 3 patients are adult female. The study was conducted in an MDCT (GE optima 660) scanner. The split bolus technique protocol followed in this study is an initial bolus of 40 mL contrast media given intravenously at 3.5 mL/second flow rate with an interbolus delay of 8–10 minutes to allow the contrast media opacify the ureter and urinary bladder. After 8–10 minutes, the remaining 50 mL of contrast media and 20 mL saline chaser are given, and images were acquired at 25 seconds for the arterial phase and 70 seconds for the venous phase, nephrogenic and excretory images in a single acquisition, which eliminates the need of separate acquisition.
Results: The image quality of the split bolus technique provides comparable results with a single bolus technique for interpretation. The total dose length product (DLP) of the split bolus technique is less than the single bolus technique. So, as a result, the radiation dose is reduced in the split bolus technique. The entire procedure from patient preparation to postprocedure care ranges from 35 to 55 minutes, and the scan time is similar for both the techniques. In our study, various pathologies were also diagnosed, such as, renal cyst was reported in 40% of the patients, and other diseases like hydronephrosis, renal calculus, contracted, a lesion in the kidney, and pyelonephritis were diagnosed in the rest of the patients.
Conclusion: The split bolus technique can be considered for reducing radiation exposure to the patient for the CTU examination. The split bolus technique has some limitations compared to the single bolus technique. Nevertheless, split bolus gives comparable image quality with the less patient dose, making the technique considered for various contrast-enhanced CT investigations.
Rubin GD. Computed tomography: revolutionizing the practice of medicine for 40 years. Radiology 2014;273(2):S45–S74. DOI: 10.1148/radiol.14141356.
Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med 2009;169(22):2078–2086. DOI: 10.1001/archinternmed.2009.427.
Battal B, Kocaoğlu M, Akgün V, İnce S, Gök F, Taşar M. Split-bolus MR urography: synchronous visualization of obstructing vessels and collecting system in children. Diagn Interv Radiol 2015;21(6):498–502. DOI: 10.5152/dir.2015.15068.
Exhibit E, Valle C, Bonaffini PA, Barletta A, Faenza S, Invernizzi F, et al. Split-bolus MDCT urography technique: clinical applications, imaging findings and radiation dose exposure. 2017. 1–23.
Muenzfeld H, Mahjoub S, Roehle R, Pelzer U, Bahra M, Boening G, et al. Split-bolus vs. multiphasic contrast bolus protocol in patients with pancreatic cancer or cholangiocarcinoma. Eur J Radiol 2019;119(July):108626. DOI: 10.1016/j.ejrad.2019.07.027.
Cheng K, Cassidy F, Aganovic L, Taddonio M, Vahdat N. CT urography: how to optimize the technique. Abdom Radiol 2019;44(12):3786–3799. DOI: 10.1007/s00261-019-02111-2.
Dahlman P, Jangland L, Segelsjo M, Magnusson A. Optimization of computed tomography urography protocol, 1997 to 2008: effects on radiation dose. Acta radiol 2009;50(4):446–454. DOI: 10.1080/02841850902821757.
Chen C-Y, Hsu J-S, Jaw T-S, Shih M-CP, Lee L-J, Tsai T-H, et al. Split-bolus portal venous phase dual-energy CT urography: protocol design, image quality, and dose reduction. AJR Am J Roentgenol 2015;205(5):W492–W501. DOI: 10.2214/AJR.14.13687.
Kawamoto S, Horton KM, Fishman EK. Opacification of the collecting system and ureters on excretory-phase CT using oral water as contrast medium. Am J Roentgenol 2006;186(1):136–140. DOI: 10.2214/AJR.04.1457.
Wang ZJ, Coakley FV, Joe BN, Qayyum A, Meng MV, Yeh BM. Multidetector row CT urography: does supine or prone positioning produce better pelvecalyceal and ureteral opacification? Clin Imaging 2009;33(5):369–373. DOI: 10.1016/j.clinimag.2009.06.001.
Maheshwari E, O’Malley ME, Ghai S, Staunton M, Massey C. Split-bolus MDCT urography: upper tract opacification and performance for upper tract tumors in patients with hematuria. Am J Roentgenol 2010;194(2):453–458. DOI: 10.2214/AJR.09.3228.
Rathi V, Shah S, Nimbalkar C, Patankar K. Role of multidetector ct urography in evaluating patients with haematuria. J Evol Med Dent Sci 2016;5(59):4130–4136. DOI: 10.14260/jemds/2016/944.
Brook OR, Gourtsoyianni S, Brook A, Siewert B, Kent T, Raptopoulos V. Split-bolus spectral multidetector CT of the pancreas: assessment of radiation dose and tumor conspicuity. Radiology 2013;269(1):139–148. DOI: 10.1148/radiol.13121409.
Scialpi M, Pierotti L, Gravante S, Piscioli I, Pusiol T, Schiavone R, et al. Split-bolus versus triphasic multidetector-row computed tomography technique in the diagnosis of hepatic focal nodular hyperplasia: a case report. J Med Case Reports 2014;8(1):4–9. DOI: 10.1186/1752-1947-8-425.
Dillman JR, Caoili EM, Cohan RH, Ellis JH, Francis IR, Nan B, et al. Comparison of urinary tract distension and opacification using single-bolus 3-phase vs split-bolus 2-phase multidetector row CT urography. J Comput Assist Tomogr 2007;31(5):750–757. DOI: 10.1097/RCT.0b013e318033df36.
Manoharan D, Sharma S, Das CJ, Kumar R, Kumar P. Split bolus dual-energy CT urography after urine dilution: a one-stop shop for detection and characterisation of urolithiasis. Clin Radiol [Internet] 2020;75(8):Available from: https://www.clinicalradiologyonline.net/article/S0009-9260(20)30119-7/abstract.
Shaish H, Newhouse JH. Split-bolus CT urogram: is less more? Abdom Radiol 2017;42(8):2119–2126. DOI: 10.1007/s00261-017-1098-3.
Chow LC, Kwan SW, Olcott EW, Sommer G. Split-bolus MDCT urography with synchronous nephrographic and excretory phase enhancement. Am J Roentgenol 2007;189(2):314–322. DOI: 10.2214/AJR.07.2288.
Lai YTA, Lai BMH, Chin H, Fung KP, Shum SF, Kan WK, et al. Single-bolus versus split-bolus protocol in multidetector computed tomography urography. Hong Kong J Radiol 2017;20(2):126–130.
Joshi BRJ. A comparison of radiation dose in single and split bolus multidetector computed tomography urography. J Inst Med 2017;41(1):11–15.
Kekelidze M, Dwarkasing RS, Dijkshoorn ML, Sikorska K, Verhagen PCMS, Krestin GP. Kidney and urinary tract imaging: triple-bolus multidetector CT urography as a one-stop shop - protocol design, opacification, and image quality analysis. Radiology 2010;255(2):508–516. DOI: 10.1148/radiol.09082074.
Caoili EM, Inampudi P, Cohan RH, Ellis JH. Optimization of multi-detector row CT urography: effect of compression, saline administration, and prolongation of acquisition delay. Radiology 2005;235(1):116–123. DOI: 10.1148/radiol.2351031085.
Hage L, Boll D, Brantner P, Bongartz G, Potthast S. CT-urography: comparison of different methods for increasing the intra-abdominal pressure. Int J Diagn Imaging 2018;5(1):25. DOI: 10.5430/ijdi.v5n1p25.
Mctavish JD, Jinzaki M, Zou KH, Nawfel RD, Silverman SG. Multi-detector row CT urography: comparison of strategies for depicting the normal urinary collecting system. Radiol 2002;11:783–790. 2253011515.
Zamboni GA, Romero JY, Raptopoulos VD. Combined vascular-excretory phase MDCT angiography in the preoperative evaluation of renal donors. Am J Roentgenol 2010;194(1):145–150. DOI: 10.2214/AJR.08.1999.
Lee D, Cho ES, Kim JH, Kim YP, Lee HK, Yu JS, et al. Optimization of split-bolus CT urography: effect of differences in allocation of contrast medium and prolongation of imaging delay. Am J Roentgenol 2017;209(1):W10–W17. DOI: 10.2214/AJR.16.16459