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Vol. 30 No. 18 (2023): JPTCP (769-776) Page | 769
Journal of Population Therapeutics
& Clinical Pharmacology
RESEARCH ARTICLE
DOI: 10.53555/jptcp.v30i18.3159
“ROLE OF UNENHANCED COMPUTED TOMOGRAPHY
KIDNEY, URETER, BLADDER (CT KUB) IN THE DIAGNOSIS OF
INCIDENTAL FINDINGS”
Abdul Salam1, Girma Abdeta Bogale2, Dr. Qasim Yousaf3, Sahar Ashraf4, Dr Amjad Ali
Shah5, Abdul Wadood6*, Nazifa Tahseen7, Kazim Ali8, Kinza Fatima9, Md Ariful Haque10,
Ayesha Malik11, Muhammad Hashim Khan12
1Department of Radiology, College of Medical Technology Bacha Khan Medical College (BKMC),
Mardan - Pakistan
2Department of Medical Imaging, First Affiliate Hospital of Xi'an Jiaotong University, Xi'an,
Shaanxi - PR China
3Consultant Radiologist, Amina Anayat Medical College, Lahore - Pakistan
4Woman Medical Officer, Gujranwala Medical College Teaching Hospital Gujranwala - Pakistan
5Assistant Professor of Surgery, Northwest General Hospital and School of Medicine Peshawar -
Pakistan
6*Clinical Technologist Radiology, Hayatabad Medical Complex (HMC) Peshawar – Pakistan
7Department of Biochemistry and Molecular Biology, Tianjin Medical University, Tianjin - China
8THz Technical Research Center of Shenzhen University, Key Laboratory of Optoelectronic
Devices and Systems of Ministry of Education and Guangdong Province, College of Physics and
Optoelectronic Engineering, Shenzhen University, Shenzhen 518060 - China.
9MS(Candidate), National Center for Nanoscience and Technology, Chinese Academy of Sciences,
Beijing - China
10Department of Orthopaedic Surgery, Yan’an Hospital Affiliated to Kunming Medical University,
Kunming, Yunnan - China.
11Lecturer Department of Radiology, Pakistan Institute of Medical and Management Sciences,
Peshawar - Pakistan
12Department of Cardiology, College of Medical Technology, Bacha Khan Medical College
(BKMC), Mardan - Pakistan
*Corresponding Author: Abdul Wadood
*Clinical Technologist Radiology, Hayatabad Medical Complex (HMC) Peshawar – Pakistan
Email: abdulwadoodafridi686@gmail.com
ABSTRACT
Introduction: Incidental findings refer to results that are irrelevant to the actual purpose
of performing a diagnostic assessment. The superiority of Unenhanced Computed Tomography is
that detects ureteral stones, identifies extra-urinary abnormalities, and does not require intravenous
contrast.
Objectives: The objective of the study is to better understand the role of Unenhanced CT while
evaluating the detection of incidental findings and to determine the medical importance of incidental
findings.
Material and Method: From March 2023 to August 2023, a cross-sectional study with consecutive
sampling was conducted in the radiology department of the tertiary care hospital Hayatabad Medical
“Role Of Unenhanced Computed Tomography Kidney, Ureter, Bladder (Ct Kub) In The Diagnosis Of Incidental
Findings”
Vol. 30 No. 18 (2023): JPTCP (769-776) Page | 770
Complex Peshawar, Pakistan. The Institutional Research and Ethics Review Board (IREB) of the
Hayatabad Medical Complex Peshawar, Pakistan gave its clearance for the study. Participants' ages
ranged from 20 to 70.
Results: Of the total 320 patients, 48 (15%) patients had Incidental findings of which 30 were males
and 18 were females.19 patients included the genitourinary, 28 the non-genitourinary, and 1 had
both the genitourinary and non-genitourinary Incidental findings. The most frequent genitourinary
findings were renal cyst 7. In contrast, the most common non-genitourinary findings were
appendicitis 5, which was shown to happen most frequently in those between the ages of 20 to 29.
The most affected age group was 30 to 39. ER Physician 31 sent the majority of patients to CT
KUB, as compared to Urologists.
Conclusion: The number of incidental findings found by MDCT during the KUB examination for
possible kidney stones was much higher than that reported in other study papers. Unenhanced
computed tomography is a successful tool for identifying incidental findings and has an immense
effect on how patients are managed. Radiology technologists and radiologists' knowledge, skills,
and genuine interest play a critical role in diagnosing abnormalities other than kidney stones.
Keywords: Incidental Findings, Genitourinary, Non-genitourinary, Gynecological, Gastrointestinal
Introduction:
The term "incidental findings" refers to results that are irrelevant to the actual purpose of performing
a diagnostic assessment [1] With an average lifetime rate of 12%, urolithiasis is one of the most
common and recent diseases among urologic illnesses [2], [3]. Renal stones place a tremendous
financial burden on both emerging and developed countries [4]. Only 3% of kidney stones are silent
[5]. Nearly 8% of individuals without symptoms have urolithiasis [6]. Urolithiasis is more common
in wealthy nations and is associated with affluence than other diseases including type 2 diabetes,
hypertension, and obesity [7]. Urolithiasis is the most prevalent urologic condition in Asia.
Variations in heredity, age, weather, diet, ethnicity, and metabolic illnesses are responsible for these
variations in incidence among different locations [8]. Urolithiasis is more prevalent among white
individuals in hotter nations. Males reach their peak at ages 40 to 60; females do so at ages 30. The
prevalence risk for children under 18 is up to 3% [6]. In men, urolithiasis occurs three times more
frequently [9]. A typical ER indication is acute flank pain [10]. Urolithiasis is very prevalent in
different parts of Pakistan, with a peak recorded frequency of 12% [11]. When compared to Europe
(5-9%), Canada (12%), and the United States (13%), Asia (1-5%) appears to have a lower risk of
kidney stone development in adults. The Middle Eastern region has been indicated to have the most
cases of kidney stone patients (e.g., 20% in Saudi Arabia and Sudan, Egypt, the United Arab
Emirates, and Iran). This is likely due to the region's hot weather and a greater chance of
dehydration, which is a significant environmental factor in kidney stone development. Older men
are more likely to get the condition than women (2 to 1), and only 1% to 2% of patients with urinary
lithiasis are youngsters [12]. Other specialties in addition to urologists have been known to order CT
KUB [13]. In the 1990s, unenhanced computed tomography (CT) was initially developed for stone
imaging [14]. Non-enhanced computed tomography of the kidneys, ureters, and bladder (CT KUB)
in an emergency is the gold standard for the detection of urolithiasis [15]. Due to its accessibility,
simple usage, and high sensitivity, CT KUB is the primary test for evaluating urolithiasis [16]. It
was said to have a 94%–99% specificity range and a 95%–98% sensitivity range. NCCT's broad use
is constrained by its high ionizing dosage, high rate of accidental findings, and expensive cost [3].
However, using a thinner slice thickness improves kidney stone identification on unenhanced CT
[17]. About 10% of CT KUB exams reveal an additional source of the patient's pain [18].
This superiority of Unenhanced CT is caused by its capacity to detect ureteral stones despite their
size, location, or chemical composition, identify extra-urinary abnormalities such as appendicitis,
diverticulitis, gynecological abnormalities such as hemorrhagic cysts or ovarian torsion that mimic
renal colic and does not require intravenous contrast [19]. Particularly for stones less than 5 mm in
“Role Of Unenhanced Computed Tomography Kidney, Ureter, Bladder (Ct Kub) In The Diagnosis Of Incidental
Findings”
Vol. 30 No. 18 (2023): JPTCP (769-776) Page | 771
size, these diagnostic performances are also noticeably superior [20]. One of the main drawbacks of
CT presently is the radiation dose [21]. The ideal CT KUB dose is three times higher than IVU,
determined to be between 3-5 mSv (millisievert) [22]. Another benefit of Unenhanced CT is that it
provides a general view of the other abdominal organs and the peritoneal cavity with the potential to
detect other incidental pathological processes that may receive importance for treatment over the
management of urinary tract stones, with rapid identification and consequently early management
leading to a better prognosis. and guiding the management plan in the right direction [23]. The
American College of Radiology and the European Association of Urology currently propose using
low-dose CT in patients with severe infection and skepticism about having urinary stones, however,
the American Urological Association no longer makes any sensible recommendations [24]. Through
this study, we hope to better understand the role of Unenhanced CT while evaluating the detection
of incidental findings and to determine the medical importance of incidental findings.
MATERIAL AND METHOD
From March 2023 to August 2023, In the radiology department of the tertiary care hospital
Hayatabad Medical Complex Peshawar, Pakistan a cross-sectional study with consecutive sampling
was conducted. The Institutional Research and Ethics Review Board (IREB) of the Hayatabad
Medical Complex Peshawar, Pakistan gave its clearance for the study. The study comprised both in-
patients and out-patients (male and female) with incidental findings who visited the radiology
department and agreed to provide consent. Participants' ages ranged from 20 to 70. Patients who had
undergone surgery in the past for renal or ureteral stones, patients who lacked clinical history, or
were younger than 20 years old and unwilling to grant consent, were eliminated. 320 CT KUB
patients' collective data were gathered. The patient underwent Unenhanced CT KUB on a 128-
slice GE CT scanner in accordance with the standard protocol. The examination was carried out in
the supine position with the patient's full bladder through the symphysis pubis and 1 cm above the
liver. The scan's parameters were 120 kV and 250-300 mA, 0.5 rotation with the Standard
Algorithms, 4 mm slice thickness, and a field of view (FOV) that was adjusted for the patient's size.
For correct assessment, axial, coronal, and sagittal pictures are collected. A soft-tissue window with
2 mm coronal and sagittal reconstruction was also created. In order to verify any potential distal
ureteric calculi, further images were acquired with the patient lying on his back. At the picture
archiving and communication system (PACS) workstations, the CT KUB scans were seen. An
experienced radiology resident and a consulting radiologist with extensive expertise in radiology
imaging prepared the appropriate radiological reports. Any disagreement is resolved by a shared
understanding. The radiology team members consulted before producing their last result. Using a
data collection form, all patients who had Incidental findings were noted for each imaging. All study
data forms were routinely verified for precision, comprehensiveness, and uniformity, and any found
mistakes were immediately fixed. Each filled form was organized and then coded with a special
research identity.
Genitourinary (GU) and non-genitourinary (non-GU) results were distinguished among individuals
who had incidental findings. Additionally, the incidental findings were divided into significant and
insignificant groups. The conditions that needed the referring doctor's immediate attention for
additional treatment or investigation were within the group of significant findings. The patients were
then separated into those who required immediate medical attention, such as for acute inflammatory
diseases like appendicitis, cholecystitis, or fluid collection like pleural effusion. These categories
included GU and non-GU groups as well as major or minor diagnoses. Deferred treatments
were indicated for findings such as lymph nodes and tumors. Depending on the result and expected
medical image, additional workup with contrast-enhanced examinations or MRI was advised in such
patients. Findings of little clinical significance were categorized as benign lesions that would need
treatment later. Examples include cholelithiasis, hernias, and simple cysts. Findings deemed benign
and unlikely to call for further testing or treatment were those of no clinical significance. These are
“Role Of Unenhanced Computed Tomography Kidney, Ureter, Bladder (Ct Kub) In The Diagnosis Of Incidental
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ancient fractures that have been repaired or have not been repaired. For the purpose of verifying the
patient's incidental findings, all pertinent radiological exams and laboratory results were examined.
Clinical history was examined in the patient's medical record files and radiological referral papers.
Results:
Aside from urolithiasis and blockage, 48 (15%) of the 320 evaluable patients who had CT KUB for
suspected urolithiasis also had incidental abnormalities. There were 48 patients with Incidental
findings, 30 (62.5%) males, and 18 (37.5%) females. The most affected age group was 30 to 39,
with 14 (29.2%), followed by 40 to 49 and 20 to 29 with 11 (22.9%), 50 to 59 with 10 (20.8%), and
60 to 70 with 2 (4.2%). Urban households (27, 56.3%) and joint families (34, 70.8%) were found to
be more affected than rural residences (21, 43.8%) and nuclear families (14, 29.2%). The
professions most impacted are housewives with 15 (31.3%) and business with 14 (29.2%), while
labor and students are affected to a lesser extent with 8 (16.7%) and 6 (12.5%), respectively. Patients
with a healthy weight are 28 (58.3%), followed by those who are overweight 15 (31.3%), obese (3),
and underweight (2). Clinically, there were 24 patients (50%) with flank pain, 14 (29.2%) with
general abdominal discomfort, 2 (4.2%) with lower urinary tract symptoms, 7 (14.6%) with a
combination of flank pain and LUTS, and 1 (2.1%) with hematuria. ER Physician 31 sent the
majority of patients to CT KUB (64.6%), as compared to Urologist 17 (35.4%). The majority of
cases sent by emergency room doctors are male 23 (47.9%), a significant number of flank pain
symptoms are found at the age of 20-29 8 (16.7%), and appendicitis occurs most frequently at the
age of 20-29 4 (8.3%), according to a cross-tabulation test between gender and patients referred, age
and clinical symptoms, and age and appendicitis. According to statistical analysis using the Chi-
Square, the sign value is <0.05, indicating that (Ho) is rejected and that there is a correlation
between age and appendicitis, age and clinical symptoms, and gender in patients who are referred.
Of the 48 patients who had incidental findings, 19 (39.6%) included the genitourinary system, 28
(58.3%) the non-genitourinary system, and 1 (2.1%) the genitourinary and non-genitourinary
systems in which the patient was suffering from both pyelonephritis and cholecystitis disease. The
most frequent genitourinary finding was a renal cyst 7, which was followed by a renal mass 3, an
extra-renal pelvis 2, a horse-shoe kidney 2, pyelonephritis 2, an atrophic kidney 1, an ectopic kidney
1, and hydrocele 1 as shown in Table- 1. In contrast, the most common non-genitourinary finding
was appendicitis 5, which was followed by pleural effusion 4, ovarian cyst 3, cholecystitis 2,
cholelithiasis 2, hernia 2, pelvic phleboliths 2, firearm injury 2, mesentery lymph nodes 1,
diverticulosis 1, spondylosis 1, fracture 1, and degenerative changes 1 as mentioned in Table- 2.
Figure 1: Incidental findings Distributions
“Role Of Unenhanced Computed Tomography Kidney, Ureter, Bladder (Ct Kub) In The Diagnosis Of Incidental
Findings”
Vol. 30 No. 18 (2023): JPTCP (769-776) Page | 773
Table 1: Genitourinary Findings and its clinical significance.
Genitourinary (GU)
Incidental Findings
Frequency
Percentage
Clinical Significance
Renal cyst
7
14.6%
DT
Extra-Renal pelvis
2
4.2%
LCI
Renal Mass
3
6.3%
II
Horseshoe kidney
2
4.2%
DT
Atrophic kidney
1
2.1%
NCI
Duplex collecting system
1
2.1%
DT
Pyelonephritis
2
4.2%
II
Sponge Kidney
1
2.1%
LCI
Ectopic kidney
1
2.1%
NCI
Hydrocele
1
2.1%
II
II, requires Immediate Intervention; DT, Deferred Treatment; LCI, Little Clinical Importance; NCI,
No Clinical Importance
Table 2: Non-genitourinary findings and its clinical significance.
Non-Genitourinary (Non-GU)
Incidental Findings
Frequency
Percentage
Clinical Significance
Appendicitis
5
10.4%
II
Cholecystitis
3
6.3%
II
Cholelithiasis
2
4.2%
DT
Pancreatitis
2
4.2%
II
Spine pathology
Spondylosis
1
2.1%
DT
Fracture
1
2.1%
II
Degenerative Changes
1
2.1%
DT
Gynecological
Ovarian cyst
3
6.3%
LCI
Adnexal cyst
1
2.1%
LCI
Gastrointestinal
Hepatic cyst
1
2.1%
LCI
Mesenteric Lymph Nodes
1
2.1%
DT
Diverticulosis
1
2.1%
DT
Others
Pleural Effusion
4
8.3%
DT
Pelvic Phelboliths
2
4.2%
NCI
Firearm Injury
2
4.2%
II
Hernia
2
4.2%
DT
II, requires Immediate Intervention; DT, Deferred Treatment; LCI, Little Clinical Importance; NCI,
No Clinical Importance
Discussion:
A 128-slice GE MDCT scanner was employed in 15% of the incidental findings during the CT KUB
evaluation, which is a little more than what Ummara Siddique et al. found [1]. This could be a result
of radiologists' high awareness, extensive expertise, and deep interest in patient diagnoses to
concentrate on possible causes that are in the patient's best interest. The function of radiology
technologists is equally crucial since they examine all the vital body organs. If they spot something
suspicious, they direct the radiologists' attention to it and note it in the radiological report. A 128-
“Role Of Unenhanced Computed Tomography Kidney, Ureter, Bladder (Ct Kub) In The Diagnosis Of Incidental
Findings”
Vol. 30 No. 18 (2023): JPTCP (769-776) Page | 774
slice MDCT scanner's exceptional quality allows for the detection of small abnormalities during the
test because of its great spatial and temporal resolution. The American College of Radiology
observed that the majority of incidental findings are likely benign and frequently have little to no
clinical importance in the management of incidental findings [1]. There should be precise standards
on when and how to analyze accidental outcomes because some of them may have detrimental
effects. However, even if they may not be fatal, there are additional illnesses that are significant to
be aware of. In our study, the majority of cases sent by ER physicians are male 47.9%, and a
significant number of flank pain symptoms and appendicitis are found at the age of 20-29 with the
percentage of 16.7%, and 8.3% respectively. It shows that the majority of male patients visits
emergency room doctor and early age individuals are at high risk of flank pain and appendicitis.
Unenhanced CT has an additional advantage over the other imaging modalities in that it may
uncover unexpected outcomes while performing a CT KUB scan for possible kidney stones. All CT
scans, not just the KUB scan, have the potential to find other findings that are either less or more
important for immediate intervention. As they progress from having little clinical significance to
having much clinical significance, incidental findings of GU and non-GU are quite significant.
There are some results in both GU and non-GU that require prompt intervention and appropriate
follow-up care in order to avoid adversely affecting someone's life and creating additional issues.
Due to the urgency of the situation, those incidental findings needed to be managed at the base level
and communicated as quickly as possible to the relevant specialty. In order to induce variations in
pathology for simple detection, some abnormalities also require deferred treatments and follow-up
using alternative imaging modalities or injecting contrast material. Despite the fact that some results
are not clinically significant, CT scans can still pick them up, and radiologists note them in
radiological reports so the patient is at least aware of them which can be treated later.
Limitation of the Study:
The main limitation of the present study is that all the Computed Tomography examination was
performed without injecting contrast agent and all the patient received no follow-up care. If the
contrast agent was injected and these patients had been followed, then it is possible that the
percentage of undiagnosed malignancies would be higher.
Conclusion:
The number of incidental findings found by MDCT during the KUB examination for possible
kidney stones was much higher than that reported in other study papers. Unenhanced computed
tomography is a successful tool for identifying incidental findings and has an immense effect on
how patients are managed. The great spatial and temporal resolution of MDCT is also crucial for
quickly and accurately diagnosing both major and minor abnormalities, and it can be divided into
distinct sections for each section's convenience and to ensure that no abnormality is missed during
the examination. Radiology technologists and radiologists' knowledge, skills, and genuine interest
play a critical role in diagnosing abnormalities other than kidney stones.
Recommendation:
High-level additional research is required to examine more populations for more assessment, use
contrast agents where necessary, and conduct patient follow-up till the end.
Acknowledgments:
We thank everyone who participated and contributed the essential data.
Funding:
None
“Role Of Unenhanced Computed Tomography Kidney, Ureter, Bladder (Ct Kub) In The Diagnosis Of Incidental
Findings”
Vol. 30 No. 18 (2023): JPTCP (769-776) Page | 775
Conflicts of interest:
No conflicts of interest are disclosed by the authors.
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