Radiologist CT Urogram Template

CT UROGRAM **Scan date:** 01 November 2024 **CLINICAL INFORMATION** - 68-year-old male with a history of recurrent haematuria. - Recent episode of gross haematuria with associated right flank pain. - Previous ultrasound showed mild right hydronephrosis. **PRIOR IMAGING** - Renal ultrasound, 01/2024: Mild right hydronephrosis. No definite stone or mass identified. - Abdominal CT, 05/2023: Unremarkable. No evidence of renal calculi or mass. **Technique** - Multidetector CT scan of the abdomen and pelvis performed. - Unenhanced, nephrographic, and excretory phases obtained following intravenous administration of iodinated contrast material (Iodixanol 320, 100 ml). - Radiation dose optimisation protocols adhered to. **FINDINGS** **Unenhanced findings** - Right kidney: Mild hydronephrosis is present. No obvious obstructing calculi in the renal pelvis or proximal ureter. A non-obstructing calculus, measuring 3 mm, is noted in the right lower pole calyx. - Left kidney: Normal size and morphology. No calculi or hydronephrosis. - Bladder: Distended with clear urine. No obvious intrinsic lesions or calculi. **Post-contrast findings** - Right kidney: Uniform enhancement of the renal parenchyma in the nephrographic phase. No focal masses or perfusion defects are identified. Delayed images demonstrate contrast excretion into the dilated right renal collecting system and ureter. - Left kidney: Normal enhancement pattern. Normal contrast excretion. - Ureters: The right ureter is mildly dilated down to the vesicoureteric junction, where a filling defect, measuring approximately 5 mm, is observed. This is consistent with a calculus. The left ureter is normal in calibre. **General abdomen and pelvis findings** - Liver: Normal size and contour. No focal lesions. Segment VIII appears normal. - Gallbladder: Appears normal. No gallstones. - Pancreas: Unremarkable. - Spleen: Normal size and homogeneity. - Adrenal glands: Bilaterally normal. - Bowel: No evidence of obstruction or acute inflammatory changes. - Aorta: Mild atherosclerotic changes are noted. Abdominal aorta measures 2.2 cm at its maximum diameter. - Pelvis: No pelvic masses or lymphadenopathy. **Thorax/chest/other findings** - Lung bases: Clear. No pleural effusions or focal consolidations. - Osseous structures: Degenerative changes in the lumbar spine, L4/L5, with disc space narrowing. **CONCLUSION** - Right vesicoureteric junction calculus, 5 mm, causing mild right hydronephrosis and ureteric dilatation. - Non-obstructing right renal lower pole calyx calculus, 3 mm. - No other significant abdominopelvic pathology identified. Incidental moderate coronary artery calcification demonstrated. If the patient has associated symptoms of angina, recommend management as per chest pain guidelines, including cardiology referral if appropriate. If the patient is asymptomatic, routine cardiology referral not required, GP and/or referring clinician to consider reviewing modifiable cardiovascular risk factors and managing as per guidelines for primary prevention.