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Diagnostic Radiology - Urinary System

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Diagnostic Radiology - Urinary System Powered By Docstoc
					Uroradiology
Junior Clerkship Department of Diagnostic Radiology

Learning Objectives
• Revision of radiological anatomy of the renal tract on KUB, IVU and CT • Applications of IVU, CT and US examinations of the renal tract • Recognize radiological features of common urological conditions

KUB
• Kidneys: calcification size (21/2 vertebrae) outline position • Ureters: tips trans processes, along SIJ calcification • Bladder: calcification outline Renal and ureteric calculi Staghorn calculus

A middle aged man with right loin pain

Rounded mass in the region of the R kidney What further radiological investigations can be performed?

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IVU
• Intravenous urogram (IVU) • Ultrasound • Computed tomography • Arteriography • Intravenous administration of iodinated contrast media • Excreted by kidneys (glomerular filtration) • Opacifies the pelvicalyceal system, ureters and bladder Evaluates renal function and anatomy

IVU
A series of radiographs taken of the renal area and KUB • Preliminary KUB • 0-1 minute film • 5 minute film • 10 minute film with abdominal compression • Release film • Full bladder view • Post-micturition KUB

IVU

1 minute film Renal outline

10 minute film Pelvicalyceal system

IVU
A 5 minute film is performed to assess contrast excretion If contrast is seen within the PC system, abdominal compression is applied Why abdominal compression?

IVU

Full length KUB at 20 minutes Compression released

Preliminary KUB

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IVU
When is IVU required? • Haematuria • Renal colic • Renal masses What other urographic investigations are there?

• Antegrade pyelogram • Retrograde pyelogram • Urethrogram • Micturating cystourethrogram

• What examination is this? • How is it done?

Antegrade pyelogram
catheter

• Kidney is punctured percutaneously (US guided) • Contrast injected into the pelvicalyceal system When is it performed?

• When IVU is unsatisfactory • To show level of obstruction • When drainage procedure is required (nephrostomy) TB of the kidney with multiple calyceal and ureteric strictures

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Retrograde pyelogram
• What examination is this? • What is A? • How is it performed?
• A is a cystoscope • An ureteric catheter is inserted via the cystoscope, into the ureter & finally placed in the renal pelvis • Patient is transferred to radiology department • Contrast is injected via the ureteric catheter

A

A

Retrograde pyelogram

Retrograde pyelogram

Normal

catheter

Normal

What differences do you see?

This is another case of TB of the kidney with multiple strictures and cavities

•What examination is this? •How is it done?

Micturating cystourethrogram
• Patient is catheterised • Bladder is filled with contrast • Intermittent screening for vesico-ureteric reflux during bladder filling and micturation • Urethra and bladder base also screened For reflux, bladder and urethral abnormalities

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Micturating cystourethrogram
A 34-year-old man with previous history of pelvic trauma
C

A B

What is being done here?

Urethrogram
Contrast is injected into the urethra via a clamp or Foley’s catheter placed at the tip of the penis

Ultrasound
Evaluates: • Renal size and morphology • Renal parenchyma • Masses – cyst versus solid masses • Obstruction – hydronephrosis • Renal vessels – transplanted kidneys renal artery stenosis

To evaluate the male urethra

Ultrasound

Medullary calcification

Normal

Assessment of renal parenchyma Sagittal Transverse
Cortical echogenicity

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Hydronephrosis

Computed tomography
Indications • Further characterisation of abnormalities seen on IVU (CT urogram), KUB, US • Renal colic • Cancer staging • Renal trauma

Chronic obstruction

Normal

Computed tomography
Ant gerota’s fascia
E C D A B

Renal colic
Post gerota’s fascia

Hypodense parapelvic fat surround the kidneys

Renal cell carcinoma

Arteriography
Indications:
• tumour vascularity • diagnosis and treatment of renal artery stenosis • embolisation of bleeding tumours or points • Diagosis and treatment of AVM

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Renal artery Stenosis
Bilateral fibromuscular dysplasia How might this patient present?

Vascular tumour in right upper pole

Case 1: A 57 year-old lady with chronic right loin pain

Renal cell carcinoma

CT confirms staghorn calculus with chronically dilated pelvicalyceal system

Case 2:
A 32 year-old lady with abdominal mass and haematuria

Note thickening of gerota’s fascia and stranding of the pararenal fat. This indicates chronic inflammatory change

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IVU shows a large mass lesion distorting the right PC system Possibilities include simple cyst and tumours such as RCC or angiomyolipoma Further evaluation with US or CT would be appropriate

This was a RCC

IVU 18 months previously

Case 3: US scan of the left kidney of a 45-yr old man with haematuria

Mass

Transitional cell CA of renal pelvis
Normal

Mass

Case 4: Preliminary KUB of an IVU series of a patient with bilateral renal colic

KUB showed right intrarenal, right ureteric and left lower ureteric calculi

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• There is partial obstruction of the right kidney by an upper ureteric calculus • Poor excretion and concentration of contrast by the left kidney, which is totally obstructed by a lower ureteric stone 30-minute IVU film Preliminary KUB

Case 5: A patient with loin pain and haematuria

• Right staghorn calculus • Left ureteric calculus • Enlarged left kidney - most likely obstructed

This is the patient’s KUB 4 days later What has happened?

JJ stent has been inserted into the left kidney, to relieve obstruction ESWL has been performed on the right staghorn calculus. Note remnant flecks of calculi.

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Case 6: MCU of a child with recurrent UTI What do you see?

Mild reflux into left kidney More severe reflux

Case 6: KUB of a young lady with increasing abdominal mass

Large soft tissue mass is seen in the left abdomen, which is displacing bowel Further evaluation with CT was performed

Plain CT

Plain CT showed large mass arising from the left kidney. Smaller masses are also seen in right kidney with fat densities

Contrast CT

Contrast CT shows vascularity of these masses. Note fat densities within these masses

Typical of angiomyolipomata

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Case 7: CT scans of a young man with deranged renal function

• There are multiple cysts replacing both kidneys • Some calcification is noted in the walls of the cyst • Note cysts also in the liver • Pancreas is normal

Polycystic kidneys

Case 8: A 42-year old lady with h/o renal stones Now c/o left loin pain and fever • What could be the cause of her symptoms? • What further Ix should be performed?

• There are 3 calculi in the left kidney • Further evaluation with US or IVU is appropriate to exclude obstruction either within calyx or in the ureter

Sagittal and transverse US show focally dilated upper pole calyx secondary to a calculus
Sagittal

Case 10: IVU of a young man

Transverse

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Crossed renal ectopia Note appendicectomy sutures in the RIF

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posted:10/22/2008
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