Kombinierte statisch-dynamische MR-Urographie zur morphologisch-funktionellen Diagnostik angeborener Harntransportstörungen

Zusammenfassung

Einleitung: In dieser Arbeit beschreiben wir eine neuartige Technik - die kombinierte statisch-dynamische MR-Urographie (MRU) - die eine komplexe morphologisch-funktionelle Diagnostik angeborener Harntransportstörungen erlaubt. Material und Methode: Bislang wurden insgesamt 117 pädiatrische Patienten im Alter von 4 Tagen bis 17 Jahren (Median 12 Monate) mit 148 pathologischen und 84 normalen Nieren-Ureter-Einheiten untersucht. Eine stark T2-gewichtete IR-TSE-Sequenz liefert die dreidimensionale morphologische Darstellung der Harnwege, eine dynamische T1-gewichtete FFE-Sequenz dient der Bestimmung von seitengetrennter Nierenfunktion und Harnabfluss. Ergebnisse: Die Bildqualität wurde in 97 % als exzellent oder gut beurteilt und wurde nicht beeinträchtigt durch eine reduzierte Nierenfunktion. In insgesamt 80 % gelang die vollständige Darstellung des Harntraktes, sonst wurde meist lediglich der poststenotische Ureterabschnitt nicht abgebildet. Zwischen MRU und Szintigraphie ergab sich eine hochsignifikante Korrelation bezüglich der seitengetrennten Nierenfunktion und eine starke Übereinstimmung bezüglich des Harnabflusses. Bei Doppelnieren und dystopen Nieren war die MRU der Szintigraphie deutlich überlegen. Schlussfolgerung: Die wesentlichen Vorteile der statisch-dynamischen MR-Urographie zur Diagnostik angeborener Harntransportstörungen liegen in der fehlenden Strahlenbelastung sowie der simultanen funktionell-morphologischen Diagnostik. Besondere Vorteile bietet die Methode zur Abklärung von Doppelnieren und dystopen Nieren.

Abstract

Introduction: We describe a novel technique - combined static-dynamic MR urography (MRU) - which allows comprehensive morphological and functional diagnostic work-up of congenital urinary tract obstruction. Materials and Methods: Up to now, 117 pediatric patients ranging in age from 4 days up to 17 years (median 12 months) with 148 pathological and 84 normal kidney-ureter-units were examined. A heavily T2-weighted IR-TSE-sequence provides three-dimensional morphologic depiction of the urinary tract; a dynamic, T1-weighted FFE-sequence is used for the determination of split renal function and urinary excretion. Results: The image quality was judged excellent or good in 97 % and was not compromised by reduced kidney function. The entire urinary tract was depicted in 80 %, while, in the remaining, only the poststenotic ureter was generally lacking. MRU and scintigraphy showed a highly significant correlation regarding split renal function, and a strong agreement regarding urinary excretion. In kidneys and dystopic kidneys, MRU was clearly superior to scintigraphy. Conclusions: The essential advantages of static-dynamic MRU for the diagnosis of congenital urinary tract obstruction are the lack of radiation exposure and simultaneous functional-morphologic diagnosis. The method offers particular advantages in the evaluation of duplex and dystopic kidneys.

Schlüsselwörter

Harntrakt - Harnleiterobstruktion - Hydronephrose - Urodynamik - Magnetresonanztomographie - Urographie - Szintigraphie

Key words

urinary tract - ureteral obstruction - hydronephrosis - urodynamics - magnetic resonance imaging - urography - radioisotope renography

Literatur

• 1 Ebel K-D, Bliesener J A, Gharib M. Imaging of uretero-pelvic junction obstruction with stimulated diuresis.  Pediatr Radiol. 1988;  18 54-56
• 2 Patriquin H. Doppler examination of the kidney in infants and children.  Urol Radiol. 1991;  12 220-227
• 3 Riccabona M, Ring E, Fueger G, Petritsch P, Vilits P. Doppler sonography in congenital ureteropelvic junction obstruction.  Eur J Ultrasound. 1996;  3 203-209
• 4 Rohrschneider W, Tröger J. Pelvi-ureteric stenosis in infancy - comparison of diuresis sonography and diuresis excretory urography.  RöFo. 1992;  157 72-78
• 5 Gordon I. Pediatric aspects of radionuclides in nephrourology. In: Murray ICP, Ell PJ (Hrsg). Nuclear medicine in clinical diagnosis and treatment, 2nd. Edinburgh, London, New York: Churchill Livingstone 1998: 277-290
• 6 O'Reilly P, Aurell M, Britton K, Kletter K, Rosenthal L, Testa T. Consensus on diuresis renography for investigating the dilated upper urinary tract.  J Nucl Med. 1996;  37 1872-1876
• 7 Peters C, Manedell J, Treves T. et al . The ‘well-tempered’ diuretic renogram: a standard method to examine the asymptomatic neonate with hydronephrosis or hydroureteronephrosis.  J Nucl Med. 1992;  33 2047-2051
• 8 Roarke M C, Sandler C M. Provocative imaging. Diuretic renography.  Urol Clin North Am. 1998;  25 227-249
• 9 Aerts P, van Hoe L, Bosmans H, Oyen R, Marchal G, Baert A L. Breath-hold MR urography using the HASTE technique.  Am J Roentgenol. 1996;  166 543-545
• 10 Hattery R, King B F. Technique and application of MR Urography.  Radiology. 1995;  194 25-27
• 11 Henning J, Friedburg H. Clinical applications and methodological developments of the RARE technique.  Magn Reson Imaging. 1988;  6 391-395
• 12 Hussain S, O'Malley M, Jara H, Sadeghi-Nejad H, Yucel E K. MR urography.  Magn Reson Imaging Clin N Am. 1997;  5 95-106
• 13 Nolte-Ernsting C C, Bucker A, Adam G B, Neuerburg J M, Jung P, Hunter D W, Jakse G, Gunther R W. Gadolinium-enhanced excretory MR urography after low-dose diuretic injection: comparison with conventional excretory urography.  Radiology. 1998;  209 147-157
• 14 O'Malley M E, Soto J A, Yucel E K, Hussain S. MR urography: evaluation of a three-dimensional fast spin-echo technique in patients with hydronephrosis.  Am J Roentgenol. 1997;  168 387-392
• 15 Regan F, Bohlman M E, Khazan R, Rodriguez R, Schultze-Haakh H. MR-Urography using HASTE imaging in the assessment of ureteric obstruction.  Am J Roentgenol. 1996;  167 1115-1120
• 16 Reuther G, Kiefer B, Wandl E. Visualization of urinary tract dilatation: value of single-shot MR urography.  Eur Radiol. 1997;  7 1276-1281
• 17 Rothpearl A, Frager D, Subramanian A, Bashist B, Baer J, Kay C, Cooke K, Raia C. MR Urography: Technique and application.  Radiology. 1995;  194 125-130
• 18 Roy C, Saussine C, Jahn C, Vinee P, Beaujeux R, Campos M, Gounot D, Chambron J. Evaluation of RARE-MR urography in the assessment of ureterohydronephrosis.  J Comput Assist Tomogr. 1994;  18 601-608
• 19 Tang Y, Yamashita Y, Namimoto T, Abe Y, Nishiharu T, Sumi S, Takahashi M. The value of MR Urography that uses HASTE sequences to reveal urinary tract disorders.  Am J Roentgenol. 1996;  167 1497-1502
• 20 Verswijvel G A, Oyen R H, van Poppel H P, Goethuys H, Maes B, Vaninbrouckx J, Bosmans H, Marchal G. Magnetic resonance imaging in the assessment of urologic disease: an all-in-one approach.  Eur Radiol. 2000;  10 1614-1619
• 21 Bennett H F, Debiao L. MR imaging of renal function.  Magn Reson Imaging Clin N Am. 1997;  5 107-126
• 22 Carvlin M J, Arger P H, Kundel H L, Axel L, Dougherty L, Kassab E A, Moore B. Use of Gd-DTPA and fast gradient-echo and spin-echo MR imaging to demonstrate renal function in the rabbit.  Radiology. 1989;  170 705-711
• 23 Choyke P L, Frank J A, Girton M E. et al . Dynamic Gd-DTPA-enhanced MR imaging of the kidney: experimental results.  Radiology. 1989;  170 713-720
• 24 Frank J A, Choyke P L, Austin H A, Girton M E. Functional MR of the kidney.  Magn Reson Med. 1991;  22 319-323
• 25 Kikinis R, Schulthess G KV, Jäger P, Dürr R, Bino M, Kuoni W, Kübler O. Normal and hydronephrotic kidney: Evaluation of renal function with contrast-enhanced MR imaging.  Radiology. 1987;  165 837-842
• 26 Knesplova L, Krestin G P. Magnetic resonance in the assessment of renal function.  Eur Radiol. 1998;  8 201-211
• 27 Krestin G P. Magnetic resonance imaging of the kidneys: current status.  Magn Reson Q. 1994;  10 2-21
• 28 Laissy J-P, Faraggi M, Lebtahi R, Soyer P, Brillet G, Méry J-P, Menu Y, Le Guludec D. Functional evaluation of normal and ischemic kidney by means of gadolinium-DOTA enhanced turbo flash MR Imaging: a preliminary comparison with ^99mTc-MAG3 dynamic scintigraphy.  Magn Reson Imaging. 1994;  12 413-419
• 29 Pettigrew R I, Avruch L, Dannels W, Coumans J, Bernardino M E. Fast-field-echo MR imaging with gd-DTPA: Physiologic evaluation of the kidney and liver.  Radiology. 1986;  160 561-563
• 30 Schad L R, Semmler W, Knopp M V, Deimling M, Weinmann H-J, Lorenz W J. Preliminary evaluation: Magnetic resonance of urography using a saturation inversion projection spin-echo sequence.  Magn Reson Imaging. 1993;  11 319-327
• 31 Semelka R C, Hricak H, Tomei E, Floth A, Stoller M. Obstructive nephropathy: Evaluation with dynamic G-DTPA-enhanced MR imaging.  Radiology. 1990;  175 797-803
• 32 Sigmund G, Stöver B, Zimmerhackl L B, Frankenschmidt A, Nitzsche E, Leititis J U. RARE-MR-urography in the diagnosis of upper urinary tract abnormalities in children.  Pediatr Radiol. 1991;  21 416-420
• 33 Staatz G, Nolte-Ernsting C C, Adam G B, Hubner D, Rohrmann D, Stollbrink C, Gunther R W. Feasibility and utility of respiratory-gated, gadolinium-enhanced T1-weighted magnetic resonance urography in children.  Invest Radiol. 2000;  35 504-512
• 34 Avni F, Matos C, Rypens F, Schulman C C. Ectopic vaginal insertion of an upper pole ureter: Demonstration by special sequences of Magnetic Resonance Imaging.  J Urol. 1997;  158 1931-1932
• 35 Borthne A, Nordshus T, Reiseter T, Geitung J T, Gjesdal K I, Babovic A, Bjerre A, Loe B. MR urography: the future gold standard in paediatric urogenital imaging?.  Pediatr Radiol. 1999;  29 694-701
• 36 Borthne A, Pierre-Jerome C, Nordshus T, Reiseter T. MR urography in children: current status and future development.  Eur Radiol. 2000;  10 503-511
• 37 Fukuda Y, Watanabe H, Tomita T, Katayama H, Miyano T, Yabuta K. Evaluation of glomerular function in individual kidneys using dynamic magnetic resonance imaging.  Pediatr Radiol. 1996;  26 324-328
• 38 Rohrschneider W K, Hoffend J, Becker K, Clorius J H, Darge K, Kooijman H, Tröger J. Combined static-dynamic MR urography for the simultaneous evaluation of morphology and function in urinary tract obstruction. Part I: Evaluation of the normal status in an animal model.  Pediatr Radiol. 2000;  30 511-522
• 39 Rohrschneider W K, Becker K, Hoffend J, Clorius J H, Darge K, Kooijman H, Tröger J. Combined static-dynamic MR urography for the simultaneous evaluation of morphology and function in urinary tract obstruction. Part II: Findings in experimentally induced ureteric stenosis.  Pediatr Radiol. 2000;  30 523-532
• 40 Rohrschneider W K, Haufe S, Wiesel M, Tönshoff B, Darge K, Wunsch R, Clorius J H, Tröger J. Functional-Morphological Evaluation of Congenital Urinary Tract Dilatation using Combined Static-Dynamic MR Urography: Findings in Kidneys with a Single Collecting System. Radiology, in press 2002
• 41 Brown S CW. Nuclear medicine in the clinical diagnosis and treatment of obstructive uropathy. In: Murray ICP, Ell PJ (Hrsg). Nuclear medicine in clinical diagnosis and treatment, 2nd. Edinburgh, London, New York: Churchill Livingstone 1998: 291-313
• 42 Taplin G V, Meredith O M, Kade H. et al . The radioisotope renogram. An external test for individual kidney function and upper urinary tract patency.  J Lab Clin Med. 1956;  48 886
• 43 O'Reilly P H, Lawson R S, Shields R A, Testa H J. Idiopathic hydronephrosis - the diuresis renogram: a new non-invasive method of assessing equivocal pelviureteral junction obstruction.  J Urol. 1979;  121 153-155
• 44 Gordon I, Dhillon H K, Gatanash H, Peters A M. Antenatal diagnosis of pelvic hydronephrosis assessment of renal function and drainage as a guide to management.  J Nucl Med. 1991;  32 1649-1654
• 45 Farres M T, Gattegno B, Ronco P, Flahault A, Paula-Souza R, Bigot J M. Nonnephrotoxic, dynamic, contrast enhanced magnetic resonance urography: use in nephrology and urology.  J Urol. 2000;  163 1191-1196
• 46 Gylys-Morin V M, Minevich E, Tackett L D, Reichard E, Wacksman J, Sheldon C A. Magnetic resonance imaging of the dysplastic renal moiety and ectopic ureter.  J Urol. 2000;  164 2034-2039
• 47 Weinmann H J, Brasch R C, Press W R, Wesbey G E. Characteristics of Gadolinium-DTPA complex: a potential NMR contrast agent.  Am J Roentgenol. 1984;  142 619-624
• 48 Bubeck B, Brandau W, Weber E, Kälble T, Parekh N, Georgi P. Pharmacokinetics of technetium-^99m-MAG3 in humans.  J Nucl Med. 1990;  31 1285-1293
• 49 Hunter G J, Gordon I, Sweeney L, Todd-Pokropek A, Ransley P G. ^99mTc DTPA scanning with diuretic washout. Is it useful in the investigation of obstruction in the presence of gross renal tract dilatation?.  Br J Urol. 1987;  59 208-210
• 50 Harbert J C, Fraley E E, Deckers P J. Alteration in radioactive isotope renogram pattern with urinary bladder filled.  JAMA. 1970;  211 810-811
• 51 Koff S A, Campbell K D. Nonoperative management of unilateral neonatal hydronephrosis.  J Urol. 1992;  148 525
• 52 Ransley P G, Dhillon H K, Gordon I, Duffy P G, Dillon M J, Barratt T M. The postnatal management of hydronephrosis diagnosed by prenatal ultrasound.  J Urol. 1990;  144 584
• 53 Cartwright P C, Duckett J W, Keating M A, Snyder H M, Escala J, Blyth B, Heyman S. Managing apparent ureteropelvic junction obstruction in the newborn.  J Urol. 1992;  148 1224