THE URINARY TRACT

Methods of examination Plain film of the abdomen patient in supine position, kidneys, ureteral and bladder areas. Assessment of the size, shape and position of the kidneys, the presence of calcium, psoas muscle abnormalities. IVU i.v. injection of radioopaque contrast medium. Serial films are obtained over 15 to 25 minutes as the contrast agent is excreted by the kidneys for visualization of the renal collecting system, ureters and bladder (first film obtained after 1 minute and a second film after 5 minutes).Compression film. Patient preparation bowel cleansing to remove gas and fecal matter from the colon.Contraindications to injection of i.v. contrast medium : - hypersensitivity to the contrast agent - renal and hepatic disease - asthma - a serum creatinine level higher than 3mg/100ml - multiple myeloma - history of severe allergy

US CT MRI Retrograde pyelography cystoscopy and catheterization of the ureters are necessary. Antegrade pyelography a needle is placed percutaneously into the renal pelvis from a posterolateral approach and either fluoroscopic or ultrasonic guidance is used. Conventional percutaneous nephrostomy, brush biopsy, stent placement, stone dissolution or extraction, pressure flow study, dilatation of stenosis can be performed using the access gained to the collecting system. Renal angiography first global aortography followed by selective renal artery catheterization. Used for renal angioplasty/stenting and renal embolization. Cystography after voiding a urethral catheter is inserted and the bladder is filled with contrast medium. Indications: bladder rupture, tumors, diverticula. Renal scintigraphy 99Tc and 131I. Indication renal function.

Anomalies in number
Renal agenesis single kidney. Method of choice angiography. Supernumerary kidney the usual finding is that the anomalous kidney is small and the other kidney on the same side is often smaller than the normal kidney on the opposite side.Demonstration of the presence of a separate pelvis, ureter and blood supply is necessary to make the diagnosis.

Anomalies in size and form

Hypoplasia usually associated with hyperplasia on the other. The hypoplastic kidney functions normally.It must be differentiated from the acquired atrophic kidney which is small and contracted because of vascular or inflammatory disease.In congenital hypoplasia the collecting system is small and there is a normal relation between the amount of parenchyma and the size of calices and renal pelvis. Hyperplasia is associated with agenesis or hypoplasia on the opposite side (more properly termed compensatory hypertrophy). Conditions that usually cause bilateral renal enlargement: acute glomerulonephritis, lymphoma, leukemia in children, systemic lupus erithematosus, polycystic disease, bilateral renal vein thrombosis, amyloidosis, sarcoidosis, lobular glomerulonephritis, total lipodystrophy.

Fusion anomalies
Horseshoe kidney the lower poles of the kidney are joined by a band of soft tissue, the isthmus. The long axis of the kidney is reversed so that the lower pole is nearer the midline than the upper.There is also an associated rotation anomaly. The calyces are directed backward or posteromedially.The ureters tend to be streched over the isthmus and partial obstruction is not unusual.This leads to dilatation of the pelvis and calyces. Do CT !!! Crossed ectopy fusion of the kidneys on the same side; the lower one is ectopic and its ureter crosses the midline to enter the bladder normally on the opposite side. Do CT &US

Anomalies in position
Malrotation results from incomplete or excessive rotation and urographic study indicates the degree of anomaly. Ectopy pelvis, thorax. Do CT !!! Nephroptosis downward displacement and more mobility of the kidney than usual.

Anomalies of the renal pelvis and ureter Ureteropelvic junction anomalies usually bilateral but not always simmetrical. Duplication of the pelvis and ureter Retrocaval ureter is limited to the right side.The ureter passes to the left behind the IVC. Ureterocele intravesical dilatation of the ureter immediately proximal to its orifice in the bladder.It varies in size from a small dilatation to one that is moderately large and resembles a cobra head in shape.When the ureterocele is not filled with contrast it appears as a radiolucent mass within the opacified bladder in the region of the ureteral orifice.If it is filled, the lesion is outlined by a radiolucent wall that stands out in contrast to the filled bladder and to the filled, dilated, distal ureter. Ureteral diverticula

OBSTRUCTIVE UROPATHY
Nonobstructive hydronephrosis diabetes, infections, appendicitis, peritonitis Congenital hydronephrosis obstruction at the UPJ, vesicoureteral reflux, congenital ureterocele, urethral valves, congenital strictures. Acquired hydronephrosis tumors, calculi, strictures, radiation therapy, surgery, prostatic enlargement, pregnancy in the third trimester,abdominal aortic aneurysm. Imaging findings - US method of first choice to evaluate patients with suspected hydronephrosis (mild, moderate, severe). - CT + i.v.contrast medium useful to assess the cause of obstruction. - Urography early : flattening of the normal concavity of the calyx and a blunting of the sharp angle produced by the papilla + decrease in the rate of contrast material accumulating in the collecting system. Calyces then gradually enlarge with progressive destruction of parenchyma. A prolonged and increasingly dense nephrogram is characteristic of acute renal obstruction. In severe cases do percutaneous nephrostomy.

CALCULI Incidence 5% of population; 20% at autopsy.Recurrence of stone disease 50%. Predisposing conditions calyceal diverticuli, renal tubular acidosis, hypercalcemia, hypercalciuria. The radiographic density of a calculus depends on its calcium contents: - Calcium calculi (opaque) 75% - calcium oxalate and phosphate. - Struvite calculi (opaque) 15% - magnesium ammonium phosphate:infection stones; struvite is usually mixed with calcium phosphate to create triple phosphate calculi. - Cystine calculi (less opaque) cystinuria. - Nonopaque calculi uric acid, xanthine, mucoprotein matrix calculi in poorly functioning, infected urinary tract.

Radiographic features Calculus (determine size, number, location) Radioopaque calculus are best detected on KUB or helical CT Radiolucent calculi are best detected by IVU Renal calculi can be detected by US hyperechoic focus, posterior shadowing IVU Delayed and persistent nephrogram due to ureteral obstruction Ureter distal to calculus is narrowed (edema, inflammation), may create false impression of stricture Ureter proximal to calculus is persistently minimally dilated steinstrasse several calculi are bunched up along the ureter CT CT detects most calculi regardless of calcium content Helical CT is very useful to detect small calculi

Location 3 narrow sites: UPJ, at crossing of ureter with iliac vessels, UVJ Complications: - Forniceal rupture (pyelosinus backflow) - Chronic calculous pyelonephritis - XGP Treatment options: -Small renal calculi ( 2,5cm) ESWL (extracorporeal shock wave lithotripsy) - Large renal calculi (" 2,5 cm) percutaneous removal - Upper ureteral calculi ESWL - Lower ureteral calculi ureteroscopy Differential diagnosis - Gallstones - Calcification of costal cartilage - Calcified mesenteric nodes - Calcifications in cysts and tumors - Vascular calcification

Staghorn calculus

URINARY TRACT INFECTION Acute pyelonephritis Acute bacterial infection of the kidney and urinary tract Proteus, Klebsiella, E.Coli Role of imaging studies: - Define underlying pathology obstruction, reflux, calculus - Rule out complications abscess, emphisematous pyelonephritis Types Focal type lobar nephronia Diffuse type more severe and extensive Radiographic features - Renal enlargement (edema) - Loss of corticomedullary differentiation (edema) - IVU delay of contrast excretion, narrowing of collecting system, striated nephrogram, - Areas of decreased perfusion by CT

Chronic pyelonephritis Criteria for diagnosis: - The disease is centered in the medulla, with scarring eventually affecting the entire thickness of renal substance - There is an irregular surface depression over the involved area - The involved papilla is retracted because of scarring with secondary dilatation of its calyx - The dilated calyx has a smooth margin but variable shape - Renal tissue adjacent to the involved area is normal or hypertrophied with a sharp definition between normal and abnormal - Distribution is unifocal or multifocal involving one or both kidneys - There is an decrease in size of the involved kidney

RENAL ABSCESS Usually caused by gram negative bacteria. Underlying disease calculi, obstruction, diabetes, AIDS. Radiographic features Well-delineated focal renal lesion Central necrosis Thickened abscess wall with contrast enhancement Perinephric inflammatory involvement Complications: retroperitoneal spread of abscess, renocolic fistula

TUBERCULOSIS GU tract is the second most common site of TB involvement after the lung.The disease is typically due to hematogeneous spread. Clinical history of pulmonary TB, pyuria, hematuria, dysuria Radiographic features Distribution unilateral involvement is more common 70% Size early- kidneys are enlarged, late- the kidneys are small, autonephrectomy Parenchyma Parenchymal calcifications curvilinear, mottled, amorphous Papillary necrosis Tuberculoma Parenchymal scarring Collecting system Infundibular stenosis Amputated calyx Corkscrew ureter multiple stenosis pipestem ureter refers to a narrow, rigid aperistaltic segment

CYSTIC DISEASE Symple cysts Probably arise from obstructed tubules or ducts.They do not communicate with the collecting system. Clinical most commonly asymptomatic; rare hematuria, HTN Radiographic features IVU lucent defect, cortical bulge, round indentation on collecting system US anechoic, sharply marginated, smooth walls, very thin septation may be seen CT smooth cyst wall, sharp demarcation from surrounding renal parenchyma, water density that is homogeneous, no enhancement.

Complicated cysts Bosniak classification: - category 1 lesions benign simple cyst - category 2 lesions these minimally complicated cysts are benign but have certain radiologic findings of concern.This category includes septated cysts, minimally calcified cysts, high-density cysts - category 3 lesions complicated cystic lesions that exibit some radiologic patterns also seen in malignancy. This category includes multiloculated cystic nephroma, complex septated cyst, heavily calcified cyst and cystic renal cell carcinoma.Surgery is usually performed - category 4 lesions clearly malignant lesions with large cystic component. Irregular margins, solid vascular elements

ADULT POLYCYSTIC KIDNEY DISEASE Cystic dilatation of collecting tubules as well as nephrons. Autosomal dominant trait. Clinical slowly progressive renal failure. Treatment dialysis, transplant. Associated findings hepatic cysts, intracranial aneurysm, cysts in pancreas and spleen. Radiographic features -kidneys are enlarged and contain innumerable cysts, creating a boselated surface. -They do not communicate with the collecting system - calcification of cyst wall is common - pressure deformities of calyces and infundibula - swiss-cheese nephrogram

BENIGN TUMORS Angiomyolipoma Hamartomas containing fat, smooth muscle and blood vessels. Treatment small lesions are not treated; large and symptomatic lesions are resected or embolized Complication tumors may spontaneously bleed because of their vascular elements CT method of choice Adenoma Low grade adenocarcinoma with no metastatic potential. Usually detected at autopsy Oncocitoma These tumors arise from oncocytes of the proximal tubule. Radiographic features central stellate scar (CT) , well-defined sharp borders Juxtaglomerular tumor (reninoma) Secretion of renin causes HTN, hypernatremia, hypokalemia. Tumors appear as small hypovascular masses

RENAL CELL CARCINOMA Synonyms renal adenocarcinoma, hypernephroma, clear cell carcinoma Clinical hematuria, flank pain, palpable mass, weight loss, paraneoplastic syndrome: hypertension (renin), erythrocytosis (erythropoietin), hypercalcemia (PTH), gynecomastia (gonadotropin), Cushing syndrome (ACTH) Risk factors tobacco, phenacetin long term use, Von HippelLindau disease, chronic dialysis, family history

Radiographic features IVU renal mass with renal contour deformity, calyceal displacement and destruction US hyperechoic, nonhomogeneous, irregular borders CT hypodense mass, enhancement, calcifications, necrosis, irregular borders Angiography hypervascular, caliber irregularities of tumor vessels, prominent AV shunting, venous lakes, preoperative embolization
Staging Stage I tumor confined to kidney Stage II extrarenal but confined to Gerotas fascia Stage III A venous invasion; B- lymph node metastases ; C both Stage IV A direct extension into adjacent organs ; B metastases (lung, liver, bone, adrenal, contralateral kidney) Therapy radical nephrectomy, chemotherapy, radiotherapy

Renal pelvis tumors transitional cell carcinoma Tumors are often multifocal ureter, bladder. Radiographic features irregular filling defect, wall thickening, polypoid mass. Staging Stage I mucosal lamina propria involved Stage II into but not beyond muscular layer Stage III invasion of adjacent fat / renal parenchyma Stage IV - metastases