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Normal CT Urogram Report Template (Three-Phase)
Normal three-phase CT urogram report template: noncontrast, nephrographic and excretory phases, urothelium and collecting systems, with Bosniak and stone notes.
EXAMINATION: CT urogram. CLINICAL HISTORY: [indication] COMPARISON: None available. TECHNIQUE: Axial helical images through the abdomen and pelvis before intravenous contrast and in the nephrographic and excretory phases following intravenous contrast administration, with coronal reformats and maximum-intensity-projection images of the urinary tract. FINDINGS: Kidneys: Normal size, with symmetric nephrographic enhancement. No solid or cystic renal mass. No renal calculus on the noncontrast phase. No hydronephrosis. Collecting systems: Prompt symmetric excretion. The calyces and renal pelves opacify normally on the excretory phase, without filling defect or urothelial thickening. Ureters: Opacified throughout their course and normal in caliber bilaterally. No filling defect, stricture or periureteral stranding. Bladder: Distended, with a normal contour. No filling defect, mass or wall thickening. Solid organs: The liver, gallbladder, pancreas, spleen and adrenal glands are unremarkable. Bowel: No obstruction or mass. Lymph nodes: No lymphadenopathy by size criteria. Vessels: The abdominal aorta is normal in caliber. Bones: No acute osseous abnormality or suspicious lesion. IMPRESSION: 1. No urinary tract calculus, hydronephrosis or urothelial filling defect on this three-phase examination.
Dictation notes
- Search for calculi on the noncontrast phase only — excreted contrast hides a stone completely on the later phases.
- A nonopacified ureteral segment on the excretory phase is usually peristalsis, not a lesion — name the segment and work it with delays or prone images before calling a filling defect.
- An incidental renal cyst on a three-phase study is fully characterizable — give it a Bosniak class rather than “too small to characterize”.
Related references
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