Junior Clerkship Department of Diagnostic Radiology
• 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
• 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?
• 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
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
1 minute film Renal outline
10 minute film Pelvicalyceal system
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?
Full length KUB at 20 minutes Compression released
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?
• 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
• 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
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?
• 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
A 34-year-old man with previous history of pelvic trauma
What is being done here?
Contrast is injected into the urethra via a clamp or Foley’s catheter placed at the tip of the penis
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
Assessment of renal parenchyma Sagittal Transverse
Indications • Further characterisation of abnormalities seen on IVU (CT urogram), KUB, US • Renal colic • Cancer staging • Renal trauma
Ant gerota’s fascia
E C D A B
Post gerota’s fascia
Hypodense parapelvic fat surround the kidneys
Renal cell carcinoma
• tumour vascularity • diagnosis and treatment of renal artery stenosis • embolisation of bleeding tumours or points • Diagosis and treatment of AVM
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
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
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
Transitional cell CA of renal pelvis
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
• 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.
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 showed large mass arising from the left kidney. Smaller masses are also seen in right kidney with fat densities
Contrast CT shows vascularity of these masses. Note fat densities within these masses
Typical of angiomyolipomata
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
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
Case 10: IVU of a young man
Crossed renal ectopia Note appendicectomy sutures in the RIF