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Outline

• Introduction to imaging modalities of the urinary system

• Case base learning of common diseases in urinary tract

Diagnostic Investigations in Urinary System

• PLAIN KUB

• EXCRETORY UROGRAPHY

• RETROGRADE PYELOGRAPHY

• ULTRASOUND

• COMPUTED TOMOGRAPHY

• MAGNETIC RESONANCE IMAGING

• ANGIOGRAM

• PLAIN RADIOGRAPHY: PLAIN KUB

• EXCRETORY UROGRAPHY

• RETROGRADE PYELOGRAPHY

• ULTRASOUND

• COMPUTED TOMOGRAPHY (CT)

The general used investigations in

urinary tract system

PLAIN RADIOGRAPHY

Density levels

1. Air density

2. Fat density

3. Soft tissue/fluid/water density

4. Bone/calcific density

5. Metallic density

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1

4

2

PLAIN KUB

• Renal shadows

• Psoas shadows

• Bladder shadow

• Calcification

• Bony structure

• Other soft tissue structures: liver/spleen, abnormal mass

STAGHORN STONE

8

9

VESICAL STONE

Excretory Urography

• Intravenous pyelography: IVP• Intravenous urography: IVU• Advantages

-Anatomy: kidney and collecting system-Excretory function-Obstructive uropathy

10

Excretory Urography

• Scout image

• Dynamic study

- 1-min film / 5-min of both kidneys

- 10- min or other delayed images

- full bladder image

• Post-void image

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Normal Pyelogram (IVP 5 min)

renal papilla

minor calyx

renal papilla

major calyx

renal pelvis

ureter

13

NORMAL IVP

Excretory Urography

1. Anatomy: Renal size, shape, axis and position

2. Excretory function: normal, delay, poor, no excretion

3. Obstructive uropathy: hydronephrosis, hydroureter

4. Distortion or destruction of collecting system

5. Filling defect in pelvocalyceal system, ureter or bladder

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A 55-year-old man with hematuria

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Retrograde Pyelography (RP)

• Direct injection of contrast medium into pelvicalyceal system or ureters via the catheter

• Demonstrates pelvicalyceal system and ureters

• Limitations

- invasive technique: cystoscope

- cannot evaluate renal function

18

Retrograde Pyelography

Indications

• Evaluate collecting system in patients with hematuria

• Findings on IVP, US, or CT are not clear

• Poor renal excretion

Contraindication

• Urinary tract infection

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ULTRASOUND (US)

• Safe and cheap

• Portable

• No radiation

• No intravenous contrast medium

• Advantages for patients with renal failure, children and pregnancy

• Limitation to evaluate renal function or obese patient

KIDNEY

Normal sonographic finding

• Shape: bean shape

• Size: 9-12 cm. in long axis

• Echogenicity:

- Renal parenchyma: hypoecho and 1 cm in thickness

- Central part or renal sinus: hyperecho

HYDRONEPHROSIS

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CHRONIC RENAL DISEASE

NORMAL BLADDER

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Color-Doppler Ultrasound

• Evaluate renal vascular disease

- Renal artery

- Renal vein

• Evaluate tumor vascularization

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Color-Doppler Ultrasound

COMPUTED TOMOGRAPHY (CT)

Indications

• Detection and characterization of adrenal gland,

KUB system and pelvic organ

• Evaluate retroperitoneal disease

• Staging tumor and follow up after treatment

Limitations

• Pregnancy: radiation

• Renal insufficiency/failure : CT need IV contrast

medium administration

Renal cell carcinoma

CT Urography (CTU)

CT ANGIOGRAPHY (CTA)

Outline

• Introduction to urinary tract

• Case base learning of common disease in urinary tract

Hematuria

Causes of hematuria

• Stone

• Tumor

• Infection

Case 1 : A 46-year-old woman with right colicky pain and hematuria

Urinary calculi

• Opaque stones : calcium oxalate, carbonate, phosphate

• Poor density stones : uric acid, xanthine, cystine

Urinary calculi

Plain KUB / IVP

• Location: calyx, renal pelvis, ureter, bladder

• Shape: staghorn, round/oval (ureteric stone), lamellation (vesical stone)

IVP

• Severity and location of obstruction

• Renal function

Semiopaque vesical stones

Differential diagnosis

Filling defects in collecting system

• blood clot

• tumor

• stone

• fungal ball

• polyp

• air bubble

Urinary calculi

Ultrasound

• Diagnosis of non-opaque stone

echogenic material with acoustic shadow

• Severity and location of obstruction

• Renal size and cortical thickness

Vesical stone

Renal stone with hydronephrosis

Urinary calculi

CT scan Lt.renal stone

Lt.renal stone

Quiz : Renal or extrarenal calcification?

Extra-urinary calcific shadows

1. Calcified costal cartilage2. Calcified mesenteric LN3. Calcified iliac and splenic vessels4. Phleboliths5. Gallstones, CBD, and cystic duct stones6. Transverse process of L-spine7. Intestinal content8. Calcified appendicolith9. Pancreatic calcification

Case 2 : A 50-year-old woman with underlying DM presented with fever and sepsis

Case 2 : A 50-year-old woman with underlying DM and present with fever and sepsis

Emphysematous pyelonephritis

• Rare, life-threatening condition

• Severe pyelonephritis with gas-producing organism (Gram-neg. bacilli: E.coli)

• Elderly diabetic patient (DM 87 – 89 %)

• Clinical symptoms & signs : chills, fever, flank pain, lethargy, confusion, septicemic shock

Emphysematous pyelonephritis

IVP• Gas bubbles in renal bed, upper renal collecting

system• Renal enlargement • Delayed or absent renal excretion• Obliteration of the renal pelvis CT• Investigation of choice • Intraparenchymal, intracalyceal, intrapelvic gas

and extension into perinephric space

Case 3: Spot diagnosis ?

Renal Tuberculosis: Typical Findings

• Early : difficult to detect due to miliary tubercles in renal parenchyma

• Moderate : minimal irregularity of pyramid, fornix or isthmus

: destruction of papilla

: isthmus stenosis due to fibrosis

: deformity of pelvicalyceal system

: cavity (caseous material & necrosis)

: reduction in renal size

• Severe : nephrocalcinosis (putty calcification)

: autonephrectomy

Case 4: Spot diagnosis ?

HORSESHOE KIDNEY

• Most common renal anomaly (1:400 live birth)

• Male : female = 2:1

• Midline connection may be by functioning renal perenchyma or fibrotic band

Case 5: Diagnosis ?

SIMPLE CYST

• The most common renal masses ~ 65-70 % of cases

• Occur in patients > 50 years old

• Solitary or multiple

• Bilateral cysts: less common

• Size: variable

• No symptom, incidental finding

• Serous containing

SIMPLE CYST

US

• well defined, smooth wall

• anechoic

• posterior enhancement

CT

• homogeneous water density

• thin septation may be identified

• no enhancement

Case 6: A 60-year-old man with hematuria

Renal cell carcinoma (RCC)

• Most common primary malignant renal tumor in adults

• Male : female = 2.5:1• Age : 50-70 years

Increased incidence • Tobacco• Acquired cystic disease of uremia• Hemodialysis


Clinical presentation:

•Classic triad:

gross hematuria (60%)

flank pain (50%)

palpable renal mass (<10%)

•Distant metastases: lung, bone, liver and brain


IVP

• distortion, enlarged renal portion

• displaced / obliterated collecting system, filling defect

• diminished function

• soft tissue mass

US : Hyperechoic mass with inhomogeneityCT : Hypervascular renal mass

Case 7: What is it?

Case 8: What is type of calcification?

Which cases did you learn today?

1.Calculous disease D/D calcification on plain KUB

2.Infection – bacterial, TB

3.Renal cystic disease

4.Congenital anomaly - horseshoe kidney

5.Renal tumor

6.Calcified ovarian dermoid/uterine fibroid myoma

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REFERENCES

1. Armstong P, Rockall A, Wastie M. Diagnostic imaging. 6th ed. Williston: Wiley Blackwell; 2009

2. Dunnick R, Sandler C, Newhouse J. Textbook of Uroradiology. 5th ed. Lippincott Williams & Wilkins; 2013

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