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# Photo Album by wisam neriman ## CLICK TO ADD TITLE - ultrasound. - intravenous urography (IVU). - computed tomography (CT). - MRI - Antegrade & retrograde pyelography. - Voiding cystogram - radionuclide examinations. ### CLICK TO ADD TITLE - Ultrasound, CT and MRI are essentially used for anat...

# Photo Album by wisam neriman ## CLICK TO ADD TITLE - ultrasound. - intravenous urography (IVU). - computed tomography (CT). - MRI - Antegrade & retrograde pyelography. - Voiding cystogram - radionuclide examinations. ### CLICK TO ADD TITLE - Ultrasound, CT and MRI are essentially used for anatomical information; the functional information they provide is limited. - The converse is true of radionuclide examinations where functional information is paramount. - The IVU provides both functional and anatomical information ## CALCULI - Most renal stones are calcified and show varying density on plain x-ray films. - Pure uric acid & xanthine stones are radiolucent on plain radiography, but are well seen at CT or US. - Plain film is more sensitive than US for detecting ureteric calculi. - Stones regardless their composition are intensely echogenic (By U/S) and cast acoustic shadows ## KUB The image shows an X-ray of the kidneys, ureters, and bladder (KUB). The kidneys are outlined in green, the ureters in blue, and the bladder in red. The transverse process of the vertebrae is labeled in purple. The spleen is labeled in yellow. ## C The Image shows an X-ray of the lower abdomen. A small, round, opaque object is visible in the middle of the image. This object is likely a renal stone. ## Click to add notes - Click to add te - Densely opaque, homogeneous branching calculus ## Click to add notes - Click to add tex ## Intravenous Pyelogram (IVU) The IVU series consist of: 1. KUB film... To identify any calcification like stones or nephrocalcinosis. 2. Post contrast film... - Check that the kidneys are in their normal positions (the left is usually higher than the right) - Identify renal outlines... For any bulge or indentation. - Measure the renal length (10-16 cm) these are higher than those for renal size on ultrasound. - Calyces should be evenly distributed and symmetrical. - Its shape is normally cupped, when dilated becomes clubbed. - The normal renal pelvis is funnel shaped - The ureters are usually seen in only part of their length on any one film of an IVU. - The bladder is centrally located and should be smooth in outlines. - Often show normal smooth indentations from above due to uterus or sigmoid colon. - After micturition the bladder should be empty apart from little contrast trapped in the folded mucosa. ## The post contrast series: - IV access is required for administration of the contrast material. - The contrast dose is usually instilled at a fast (bolus) rate. - The calyces are usually not visualised in <2 minutes following contrast administration - This is the NEPHROGRAM phase. - Serial images are taken at 5-20 minutes for visualisation of the PCS and ureters...This is the PYELOGRAM or EXCRETORY phase. - Lastly take a full bladder and a post-void film. The image shows an X-ray of the abdomen. The kidneys, ureters, and bladder are visible. The image is taken after the injection of contrast material. The arrow points to the left ureter. ## Click to ad The image shows an x-ray of the abdomen. The kidneys, ureters, and bladder are visible. The image is taken after the injection of contrast material. The arrows point to the calyces, renal pelvis, and ureters. The bladder is labeled. This image is of the excretory phase and is taken at 10 minutes. ## RENAL ULTRASOUND - US is the 1st line investigation. - Normal renal ultrasound shows: - Smooth renal outlines - Renal parenchyma is of homogenous echoes that is similar or less reflective than the adjacent liver or spleen. - Renal parenchymal surround the central echo complex. - PCS and ureters are normally not visible The image shows an ultrasound of the abdomen. The liver and kidney are visible. The central echo complex is labeled. ## Renal stone The image shows an ultrasound of the kidney. A small, bright spot is visible in the upper pole of the kidney. This is likely a renal stone. ## Paragraph The image shows an ultrasound of the bladder. ## RIM DIR The image shows an ultrasound of the kidneys. The two kidneys are visible, and the renal pelvis is labeled. The dimensions of the image are D1 = 137.7 mm and D2 = 14.3 mm. ## Paragraph The image shows an ultrasound of the kidney. ## HOME INSERT DESIGN TRANSITIONS ANIMATIONS SLIDESHOW REVIEW VIEW - Click to add notes - Normal kidney - Longitudinal section - Cross section - Renal capsule: echogenic line - Renal parenchyma: outer cortex & inner medulla pyramid - Central sinus complex: high echogenicity (vessels, fat, fibrous tissue) The image shows two ultrasounds of a normal kidney, one longitudinal and one cross section. ## U Bladder The image shows an ultrasound of the bladder. The bladder is labeled. ## Kidney - Renal medulla made up of conical subdivisions known as renal pyramids - Broad base of each pyramid faces the renal cortex - Apex (=papilla) points internally - Pyramids appear striped because formed by straight parallel segments of nephrons - Papilla of each pyramid empties urine into a minor calyx → major calyx → renal pelvis → ureter The image shows a CT scan of the kidneys, with the pyramids and other renal structures labeled. The fornices are also apparent. ## Bladder: Normal - Thin, uniform wall - No intraluminal filling defects The image shows two CT scans of the bladder: one noncontrast CT scan and one excretory phase CT scan. The bladder is clearly visible on the noncontrast CT scan. On the excretory phase CT scan, the bladder is slightly less defined, but it is still visible. ## IVU - Normal IVU - Normal - Flattening - Loss of waist - Clubbing - Balloning - Pelvic Hydronephrosis The image shows four diagrams of IVU scans. The first diagram shows a normal IVU scan. The second diagram shows a normal but with flattening. The third diagram shows a normal but with loss of waist. The fourth diagram shows a normal but with clubbing. The fifth diagram shows a normal but with balloning. The last diagram shows an IVU scan with pelvic hydronephrosis. ## add notes - Normal excretory phase of an IVU (intravenous urogram). This film was taken approximately 10 minutes following IV injection of iodinated contrast material. The kidneys are excreting contrast into non dilated calyces (arrows), renal pelvis (p), ureters (*) and bladder (B). The image shows an IVU scan of the kidneys, ureters, and bladder. The kidneys, ureters, and bladder are labeled. This image is of the excretory phase and is taken at 10 minutes. ## otes - Delayed nephrogram - Dilated calyces - Ureter not opacified The image shows an IVU scan of the kidneys and ureters. The calyces are dilated, and the left ureter is not opacified. The delayed nephrogram is labeled. ## IVU excretory phase - showing marked dilated PCS, but normal ureter... - DX congenital PUJ obstruction. The image shows an IVU scan of the kidneys and ureters. The right renal pelvis is dilated and clubbed. This is indicative of a congenital PUJ obstruction. The normal ureter is labelled. ## UROTHELIAL TUMORS - Almost all tumors that arise in the PCS are TCC. - Sometimes occur at multiple sites (so both PCSs and ureters should be examined). - IVU plays an important role in their DX. - Difficult to be seen by US because it blends with the sinus fat. - Ddx of TCC on IVU are stones and blood clots. The image shows an IVU scan. The arrows are pointing to a mass in the renal pelvis which is likely a TCC. ## CT scan - Native CT...For evaluation of any renal stones or abnormal calcification. - Cortico-medullary phase: After 35-40 seconds: The only parts of the renal tract which have enhanced are the renal arteries and the cortex. Useful for evaluation of the renal arteries (which may be reformatted as CT angiogram) and for evaluation of highly vascular renal tumors. The images show two CT scans of the kidneys, one native and one cortico-medullary phase. ## • Cl The images show two CT scans of the kidneys, one coronal and one axial. The axial image shows a large mass in the left kidney. ## ick to add notes - Contrast enhanced CT scan through the kidneys in nephrogram phase 90-100 seconds following contrast administration and would show renal lesions well. - Contrast enhanced CT scan through the kidneys in pyelogram phase (showing excretion of contrast into the collecting system). This is approximately 10-15 minutes following contrast administration and would show urothelial lesions well, such as transitional cell carcinoma, stones, blood clots. The images show two contrast enhanced CT scans of the kidneys, one in the nephrogram phase and one in the pyelogram phase. ## MRI - Calcification is not visible on MRI which is one of the main disadvantages for renal tract imaging. - Generally used in selected circumstances: - Renal artery stenosis - IVC or renal vein extension of renal tumors. - Extent of bladder or prostate cancers before surgery. - CMD is best with T1 and immediately following IV gadolinium. - PCS, ureter and bladder are best seen by T2. - Heavily weighted T2 is used to acquire MRU. The images show two MRI scans of the kidneys. ## Renal MRA The image shows an MRA of the kidneys. ## A The image shows two IVU scans of the kidneys, ureters, and bladder. The left kidney is dilated, and there is a large filling defect in the right renal pelvis. ## • Cl The images show two IVU scans of the kidneys, ureters, and bladder. The left kidney is dilated, and there is a large filling defect in the right renal pelvis. ## Antegrade&Retrograde pyelography - Their indications are limited to situations where the information cannot be achieved by less invasive means like IVU or CT to confirm a possible TCC in renal pelvis or ureter. The image shows two retrograde pyelograms. The first image shows a retrograde pyelogram of the left kidney. The second image shows a retrograde pyelogram of the right kidney. The arrows are pointing to a filling defect in the right renal pelvis. ## Ascending or retrograde urethrogram - Best to visualize and assess the anterior urethra The image shows a retrograde urethrogram of the urethra. The urethra is clearly visible, and the anterior urethra is labeled. ## Voiding cystogram - The UB is filled with iodinated contrast medium through a catheter... Films are taken during voiding via a fluoroscopy - Indications are: - Identify VUR - Posterior uretheral valve - Demonstrate the posterior urethera. The images show two voiding cystograms, one of a normal bladder, and the other of a bladder with a posterior urethral valve. ## The image shows three CT scans of the kidneys, ureters, and bladder. The right kidney is enlarged, and there is a mass in the renal pelvis. ## The images show four radiographs of the kidneys, ureters, and bladder. The first two images show the kidneys and ureters. The third image shows the bladder. The fourth image shows the urethra. ## RENAL MASSES - Almost all renal parenchymal masses are either simple cysts or malignant tumors(in adults RCC, in young children the commonest is Wilm's tumor. - Other causes of renal masses are benign masses like AML "Angiomyolipoma", abscesses, hydatid and metastasis. - US can establish wheather a mass is a simple cyst (ignore it)or solid mass (mostly RCC) - Causes of multiple renal masses include: - Multiple simple cysts - Polycystic disease. - Lymphoma. - Metastasis. - Inflammatory masses. ## SIMPLE CYSTS - Very common. - Filled with clear fluid(ie anechoic). - Show obvious echoes from the front and back walls and posterior acoustic enhancement. - Most are spherical in shape. - Imperceptible walls - Solitary or multiple,unilocular (simple)or have septations (not a simple cyst) - If contain low level echoes in dependent portion complicated by Hhg or infection. - No further investigations are needed. The image shows a renal cyst. ## ANGIOMYOLIPOMA - Most common benign solid renal masses. - Usually an incidental finding. - Contain fat thus hyperechoic on US, fat density/intensity on CT and MRI (their fatty content allows confident dx). The images shows an ultrasound and CT scan of an angiomyolipoma ## RENAL CELL CARCINOMA(RCC) - Most common malignant renal masses. - Spherical or lobulated similar density to the adjacent renal cortex. - May have areas of necrosis. - Enhances heterogeneously and less than that of the adjacent renal parenchyma. - CT is sufficiently accurate so that preoperative biopsy is rarely performed. - Staging is best by CT except for vascular invasion where MRI will be superior. - Staging parameters include : local direct spread, retroperitoneal L.Ns enlargement, liver adrenal or pancreatic metastasis and renal vein or IVC involvement. The image shows a CT scan of a renal cell carcinoma. ## RENAL CELL CARCINOMA(RCC) - Most common malignant renal masses. - Spherical or lobulated similar density to the adjacent renal cortex. - May have areas of necrosis. - Enhances heterogeneously and less than that of the adjacent renal parenchyma. - CT is sufficiently accurate so that preoperative biopsy is rarely performed. - Staging is best by CT except for vascular invasion where MRI will be superior. - Staging parameters include : local direct spread, retroperitoneal L.Ns enlargement, liver adrenal or pancreatic metastasis and renal vein or IVC involvement. The image shows a CT scan of a renal cell carcinoma. ## A The image shows two images, an MRI and CT scan. ## URINARY TRACT INFECTIONS(UTI) - Acute pyelonephritis is usually due to bacterial infection coming from the urethra. - Stones, anatomical abnormalities (eg. Bifid collecting system &horseshoe kidney) vesico-ureteric reflux, obstructive lesions and conditions like D.M. are all predisposing factors. - In adults only selected cases require imaging. - In children, once UTI is confirmed, all patients should have imaging investigations of the renal tract to identify an abnormality such as reflux, which can lead to renal damage if left untreated. ## - Blood born usually from pulmonary TB focus. - In early stages, US & IVU may be normal, later on various signs may develop: - Irregularity of the calyx (the earliest change) - Stricures of PCS or ureter may occur, the multiplicity of strictures is an important diagnostic feature. - Calcification is common (initially focal, later on the whole kidney is calcified "Autonephrectomy"). - In the bladder cause thick wall small volume bladder. The image shows an IVU scan. ## RENAL TRAUMA - The kidneys is one of the frequent abdominal organs to be injured. - 75% due to blunt trauma and 25% due to penetrating injury. - Loin pain and hematuria are the major presenting features. - CT scan with contrast is the investigation of choice. It can : - Demonstrate the perfusion status to the injured kidney. - Ensure that the opposite kidney is normal. - Show the extent of renal parenchymal damage. - Demonstrate injuries to other organs The image shows a diagram of the different grades of renal trauma. ## BLADDER TRAUMA - Intraperitoneal UB rupture (20-30%) Result from direct blow to a distended UB. Leaking of contrast to the peritoneal cavity - Extraperitoneal rupture (70-80%) Associated with pelvic bones fracture. The image shows a contrast enhanced CT scan of the bladder, and a diagram showing the different types of bladder trauma. ## PROSTATE - BPH Very common in elderly men Occur in the central zone of the prostate. - Prostatic adenocarcinoma: US cannot differentiate benign from malignant diseases. It is usually located in the peripheral zone. - Prostatic calcification It is so common that can be regarded as normal finding in elderly. It shows no correlation with the patient's symptoms and does not have any relation to prostatic CA ## CONGENITAL ANOMALIES - Bifid collecting system: The most common encountered anomaly. The two ureters may join at any level or may insert separately into the UB. In this case the ureter draining the upper moiety may drain outside the UB e.g. into vagina or urethra, such ureter is known as ectopic ureter. - Ectopic kidney: Often incidental finding. Usually located in the lower abdomen and the kidney is malrotated. Increase incidence of stones formation, hydronephrosis and chronic pyelonephritis. - Horseshoe kidney: The kidneys fail to separate and they are almost invariably joined at their lower poles. Causes increase incidence of PUJ obstruction and stones formation. - ADPKD: Familial disorder Age (35-55 years) Presented with HTN, renal failure and hematuria. Bilateral disease. The image shows a diagram of the different types of congenital anomalies.