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CT Abdomen without and with IV contrast
CT Pelvis with IV contrast
[OR: {Institution specific: CTA Abdomen and Pelvis}]
(Renal Donor Protocol)
INDICATION: Kidney living donor workup.
COMPARISON: [None*| <date>].
TECHNIQUE:
{Institution specific, with verbiage regarding post-processing per institution protocol as necessary for billing and coding purposes.}
Scan phases: [Unenhanced, Arterial and Nephrographic] Multiphasic contrast-enhanced imaging of imaging of the abdomen and pelvis. [2D and
3D reconstructions are performed to assist visualization of the vasculature.]

IV contrast: [# ml] [<Contrast agent and concentration>]
Oral contrast: [None*]
CT radiation dose: {Dose CTDLP: xxx mGy*cm, for example.}
FINDINGS:
LEFT:
Left kidney measures [# x # x #] cm (CC x AP x ML). {OR: Estimated renal volume: [ ] cc. }
Number of left renal arteries: [1| 2| >2 ]
Vasculature:
- First bifurcation of main renal artery: [# mm] from the origin.
- LEFT Accessory Renal Arteries: [none | Location from main: (i.e. cm above, below, off iliac artery etc...) ]
There are [no] [renal masses], [calculi] or [hydronephrosis].
Left renal vein: [pre-aortic][retroaortic] [circumaortic]
RIGHT:
Right kidney measures [# x # x #] cm (CC x AP x ML). {OR: Estimated renal volume: [ ] cc. }
Number of right renal arteries: [1| 2| >2 ]
Vasculature:
- First bifurcation of main renal artery: [# mm] from the origin.
- RIGHT Accessory Renal Arteries: [none | Location from main:]
There are [no] [renal masses], [calculi] or [hydronephrosis].
Right renal vein: [single], [# mm] in length.
Collecting systems: [no duplication]. {If there is duplication describe at the end of the paragraph for the particular kidney}
The celiac, SMA and IMA [are patent][ ]. The common, internal and external iliac arteries [are patent][].
The IVC is [normal* | duplicated | Left sided].

Remainder of Abdomen and Pelvis:
{May substitute personal preference term to signify “absent an abnormality” such as “normal” “unremarkable” etc”}
Liver: [Normal or Unremarkable*| One or more simple cysts present, none greater than 2 cm diameter].
Gallbladder and biliary system: [Normal| Unremarkable]. [No CT evident gallstones*|Cholelithiasis present.] [No biliary ductal dilatation.]
Spleen: [Normal| Unremarkable].
Pancreas: [Normal| Unremarkable].
Adrenal glands: [Normal| Unremarkable].
GI tract: [Normal| Unremarkable].
Peritoneum/retroperitoneum: [Normal| Unremarkable]. [No ascites]. [No adenopathy].
Pelvic structures: [Normal| Unremarkable.] [No pelvic lymphadenopathy.]
Body wall and musculoskeletal: [Normal| Unremarkable].
Visualized lower thorax: [Normal| Unremarkable]. [No pulmonary parenchymal mass or pleural effuson.]
IMPRESSION:
1. [Single] left renal artery with [ ] left renal vein.
[Single] right renal artery with [single] right renal vein(s).
No [hydronephrosis], [renal mass] [or calculus].
2. Otherwise [Normal | Unremarkable] CT Abdomen and Pelvis.