KIDNEY URETER BLADDER

 

Course or ureters Anterior to psoas at L4-L5

 

 

     

KUB is variously called a plain film or scout film. It is done primarily to IVP Difference in x-ray attenuation between the kidneys and the enveloping perineal fat in plain films provides a crude index of renal anatomy and pathologic changes. Preliminary to IVP Since IV contrast can hide the calculi (same x-ray density as contrast) it serves as the film oft reference for all subsequent films done after injection of contrast material. Good to pick up calcifications. Observe for calcifications over kidney, ureters, bladder regions and rest of the abdomen Can identify distended bladder Can identify abdominal and pelvic masses. Observe renal outline for size and mass density. Incidental non diagnostic findings on KUB may alert the physician to the possibility of urinary tract injury In trauma fracture of vertebrae, ribs or pelvis alerts you to GU tract injury Psoas obliteration and concavity of spine towards the side of pathology Abnormal air collections suggestions of renal or perirenal abscess

Scout Film       Any calcification over kidney, ureters, bladder regions and the rest of the abdomen Skeleton Spine Transverse processes Pelvis Soft Tissue o Psoas shadows o Margins of kidneys o Bladder distention Bladder    Size Displacement and extrinsic pressure Lumen for filling defects

Nephrogram Phase        Kidney Size 11-13cm Shape: bean shaped Contour: smooth Thickness of cortex: uniform Axis: tilted Superior pole closer to mid line

Collecting System    Calyces Sharp and pointed Dark area around collecting system duct to fat in hilum

Limitations   Contrast complications May aggravate an existing urinary tract infection or triggering one from the catheterization

Utility/Indications    Children with urinary tract infections Reflux is detected if contrast is seen to flow in retrograde fashion up the ureters from the bladder Pelvic trauma where rupture of the bladder or urethra is suspected o If the bladder is ruptured, extravasations of contrast will be seen outside the bladder in the pelvis or abdomen o If urethra is ruptured, there is extravasations into the perineum

Disadvantages     Labor and time intensive it may take up to 6 hours to complete in the severe obstruction It requires placement of an intravenous line Requires a bowel preparation for optimal results Involves intravenous injection of potentially allergic and mildly nephrotoxic contrast

How it is done      Avoiding cystourethrogam is performed by inserting a catheter into the urethra Contrast material is then instilled into the bladder through the catheter x-rays are taken before, during and after filling of the bladder when the bladder is full, the catheter is removed while the patient voids, additional x-rays are taken

Retrograde Pyelogram y Like IVP, retrograde pyelography relies on contrast medium to produce detailed x-ray images of the urinary tract

Images of the urinary tract Indications  Commonly performed when IVP produces an inadequate picture. Useful to study urinary tract obstruction when further calcification of nature of utreteral obstruction is required It also complements cytoscopy while investigating a patient with hematuria or recurrent or suspected cancer Detects small lesions in the collecting system. E.g. transitional cell carcinoma

Limitations

 Utility      

Indication y y y y y y Ultra fast CT is considered preferable to KUB for detection of suspected stones If ultrasound evaluation is equivocal for a cyst, or is suggestive of malignancy In evaluating solid abdominal masses Hematuria Local staging of cancer to allow definitive surgical management if needed Renal artery and vein evaluation

Disadvantages y y y y y Requires placement of an IV line for IV contrast Exposes patient to radiation Contrast toxicity or allergy Most yong children require sedation to undergo a CT scan CT scans are relatively expensive

 

Insertion of the catheter is painful hile conventional voiding cystogrms are still necessary to evaluate the male urethra for posterior valves and bladder trauma, the majority of studies today re done effectively with radionuclide cystograhy Images

Helpful in defining renal, bladder and prostate anatomy It is the test of choice to exclude urinary tract obstruction US can, in the majority of cases diagnose hydronephrosis Good for evaluating kidney size Good to distinguish between cysts and solid mass Good to localize kidney for biopsy

y y

y y

MRI is as good as CT or better in characterizing lesions of kidney and prostate Because of its ability to show soft tissue sin exquisite detail, MRI can detect disease and evaluate renal vasculature and inferior vena cava MRI can delineate a cyst from a solid mass It can identify the spread of kidney cancer into the renal vein, IVC and prerenal area (staging)

Disadvantages y y y Expensive Limited availability MRI has limited applicability for urinary tract since the non-specificity of its signals makes it ineffective in detecting calcifications and bladder abnormalities Patients with pacemakers, aneurysm clips, ear implants, and metallic pieces in vital body locations cannot be imaged safely.

Normal IVP

Case 1

Renal Agenesis
 when the ureteric bud fails to reach the metanephric blastema, there is no induction of nephron development associated ipsilateral abnormalities are almost always present ans include absence of ureter, hemitrigone, or vas deferens, seminal vesicle cyst, or Muellerian abnormalities such as unicornate uterus absence of the ipsilateral adrenal gland is seen in 10 % of these patients incidence of renal agenesis is one per 1000 live births, 75 % of which are male

 

Bilateral Renal Agenesis Ureterocele

  congenital saccular dilatation of the terminal portion of the ureter ectopic ureterocele enter the bladder, typically arise from the upper pole moiety of a duplicated collecting system occur in approximately 1 in every 4000 children females are affected 4-7 times more often than males a fatal anomaly occurs in one per 3000 live births, and due to oligohydramnios -these newborns present with Potter s syndromelow set ears, broad flat nose, prominent skin folds below the lower eyelids, pulmonary hypoplasia and pneumothorax   Case 4

 

Radiographic findings  a classic appearance known as the cobra head deformity and resembles a snake s head bulging into the bladder  often best detected on IVP Case 2

Multicystic Dysplastic Kidney (MCDK)

 occurs as a result of inadequate induction of maturation of the metanephric blastema by the ureteric bud

Case 3

2 Types a. Pelvoinfundibular MCDK- randomly distributed, noncommunicating cysts replace normal renal parenchyma, the kidney is not functional and an atretic ureter is often present b. Hydronephrotic MCDK- representing a severe inutero form of UPJ obstruction  both forms present with an abdominal mass detected during infancy and are associated with contralateral UPJ obstruction UPJ obstruction with associated hydronephrosis is the most common palpable abdominal mass in newborns

Medullary Sponge Kidney

 also known as benign renal tubular ectasia, it is a cystic dilatation of the collecting tubules in 1 or more renal pyramid. Urine stasis in the collecting

tubules may lead to stone formation within the ectatic tubules Case 5

-trauma (due to decreased protection) and nephrolithiasis (due to altered geometry resulting in urine stasis)  associated with other urinary tract anomalies including: -UPJ obstruction, vesicoureteral reflux, and decreased function Case 1

Case 6

Horseshoe Kidney
    occurs in one of every 400 livebirths most common renal anomaly males are twice as likely to have the anomaly as females associations include UPJ obstruction, duplication anomalies and stone formation due to abnormal kidney geometry and urine stasis

Pelvic Kidney

Renal Cysts
premature arrest of cranial ascent of the kidney a 3:2 male-to-female predominance bilateral pelvic kidneys may fuse, forming a discoid single kidney known as a pancake kidney major complications include:     50 % of the population older than 50 years most are asymptomatic, though a large cyst can cause discomfort and hypertension a ruptured cysts may result in hematuria, an infected cyst results in fever both infected cysts and hemorrhagic cysts are nonsimple by imaging Bosniak Classification of Renal Cysts by CT

   

Classification I II

III

IV

Features Simple Cyst Septated, minimal calcium described as egg shell thin, high-density cysts (>20 HU), nonenhancing M ultiloculated, hemorrhagic, dense calcifications, nonenhancing solid component Marginal irregularity, enhancing solid component

Managament Non-operative Non-operative

Renal-sparing suregery

Radical nephrectomy

   

contain hair-thin septations, faint calcifications, and/or non-simple fluis no contrast enhancement should present CT demonstrates a faint calcification (blue arrow) ultrasound clearly depicts the septum

Bosniak I Lesions  simple fluid with imperceptibly thin walls and no septations, calcifications, or enhancement  on CT, simple fluid possesses an attenuation at or around 0 HU Bosniak II Cyst

Bosniak III Cyst

  

  the cyst shows high signal on T1 and T2-weighted images suggesting it is more complex perhaps from hemorrhage or from proteinaceous contents

T2 weighted axial MRI images shows a septated mass the mass is predominantly cystic (contains high signal fluid on T2 weighted images) these septations (arrows) showed minimal enhancement on the gadolinium enhanced portion of the MRI study consistent these lesions are usually removed because of a high likelihood of malignancy

Bosniak III Lesions

Bosniak II Lesions

 

may demonstrate wall or septal thickening, bulky calcifications, or septal enhancement unenhanced CT demonstrates a lobulated cystic lesion with an irregularly calcified septum and the hint of other septa

Bosniak IV Cyst

Autosomal Dominant Polycystic Kidney Disease (ADPKD)

     shows a markedly complex cystic renal mass (red arrows) enhancement of a solid portion within the mass (yellow arrow) seen on the gadolinium enhanced images confirms this is quite likely to be a cystic renal cell carcinoma this lesion was surgically removed  an autosomal dominant disease a prevalence of 0.1 % accounting for 10 % of patients on chronic dialysis patients have multiple kidney cysts leading to enlarged palpable kidneys the disease progresses slowly, eventually resulting in end-stage renal disease and the need for dialysis or transplant

Case 3

 Case 2

55 y/o male presented with palpable mass in the right flank with pain and hematuria

Renal Cell Carcinoma

 also known as renal adenocarcinoma, hypernephroma, clear cell carcinoma, and malignant nephroma accounts for 90-95 % of primary renal cancers 50-60 years patients present with hematuria (50 %), flank pain (40 %), palpable mass (35 %), weight loss (25 %), and paraneoplastic syndrome the classic triad of hematuria, flank pain, and a palpable abdominal amss occurs in ~10 % and indicates advanced disease

  

 

30 % of patients present with metastatic disease with predilection for lung, soft tissue, bone, and liver risk factors include smoking, obesity, male (2:1), phanacetin, and other analgesics, von Hippel-Lindau disease, chronic dialysis, family history CT: enhancing mass (does not enhance as intensely as normal parenchyma) with distortion of parenchyma, collecting system and contour abnormalities, calcifications in 10 %, presence of filling defects in collecting system, renal veins and IVC US: small tumors are generally hypoechoic, large tumors hyperechoic

long term survival is possible with untreated tumor

Angiomyolipomas

        

are hamartomas containing fat, smooth muscle, and blood vessels most are asymptomatic, but may hemorrhage if large larger symptomatic lesions (>4 cm) can be resected or embolized 80 % of patients with tuberous sclerosis have AML, usually multiple lesions bilaterally CT scan: fat, appearing as a hypodense US: hyperechoic MRI: hyperintense (T1 weighted MRI) mass the presence of fat is almost pathognomonic for AML calcifications are not a common finding of angiomyolipomas and would lead towards a diagnosis or renal cell carcinoma

Case 5  MRI: the axial image shows a large mass in the right kidney and the arrow points to right renal vein invasion by the tumor. Coronal MR venogram confirms tumor thrombus in the IVC (arrow) in an advanced renal cell carcinoma

Robsons Classification Stage I  (50 % 5-year survival) confined to renal parenchyma, < 7 cm Stage II  (50 %) spread outside of renal capsule, but confined by Gerota s fascia, or >7 cm Stage III (35 %)  venous tumor extension to renal vein, infradiaphragmatic or supradiaphragmatic IVC  regional lymph node metastases  venous extension and regional lymph node metastases Stage IV (15 %)  direct invasion beyond Gerota s fascia  distant metastases  late post-nephrectomy metastases occur in 10 %

CECT scan through the kidneys in a patient with pyelonephritis and persistent fever despite antibodies shows left intrarenal fluid collection with areas of poor or no enhancement consistent with intrarenal abscess (arrows) with perinephric extension

Renal Abscess
   usually a complication of untreated pyelonephritis caused by ascending infection from gram negatives organisms (E. coli) predisposing factors include stone disease, diabetes, or AIDs

complications include retroperitoneal spread and renocolic fistula

Case 1

Bladder Carcinoma Chronic Medical Renal Disease

 a small right kidney with uniformly thin renal cortex and marked increased cortical echogenicity all points to a chronic insult to this kidney. L= liver 90 % of bladder carcinomas are transitional cell carcinomas (TCC)  75 % of which are papillary  25 % are infiltrative  other malignant neoplasms -squamous cell carcinoma (after schistosomiasis infection) -adenocarcinoma -leiomyosarcoma -lymphoma -rhabdomyosarcoma (in ages 2-6)  benign lesions include leiomyoma, fibroepithelial polyp, hemangioma, pheochromocytoma, and adenoma  Differential Diagnosis Focal mural filling defect in the bladder  common causes, such as neoplasm, stone, blood clot, or enlarged prostate gland; and  uncommon causes, such as focal cystitis, ureterocele, benign neoplasm, endometriosis, or fungus ball  Patient had fever, flank pain, costovertebral tenderness Jewett-Strong-Marshall Staging (TNM staging) 0: carcinoma-in-situ (TIS) and noninvasive papillary tumor (TA) A: papillary tumor with invasion of lamina propia (T1) B1: superficial muscle invasion (T2) B2: deep muscle invasion (T3A) C: perivesical fat invasion (T3B) D1: invasion of contiguous viscera (T4A), invasion of pelvic or abdominal wall (T4B) D2: regional lymphadenopathy (N4), distant metastases (M1)

Case 2

Pyelonephritis
  a bacterial infection of the renal parenchyma and collecting system a clinical diagnosis based on fever, flank pain, costovertebral angle tenderness, and urinary tract infection

Case 3

Cystitis
an inflammation of part or the entire urinary bladder wall  common causes include: -infection- E.coli, klebsiella, pseudomonas, schistosomiasis, also viral and fungal cause -irritative or mechanical (such as an indwelling catheter or a stone) -toxic (cyclophophamide) -radiation -allergic  CECT of the pelvis  an indwelling nephroureterical stent sits in the bladder  this patient received pelvic radiation for a nonbladder malignancy. This resulted in bladder wall thickening and obstruction of the left ureter at the ureteral orifice into the bladder causing left-sided hydronephrosis and thus requiring stenting  note bladder wall thickening in the left lateral bladder wall from radiation induced cystitis  a mass like lesion in the dependent portion of the bladder may represent a mass (arrows). However, this patient presented with gross hematuria which resolved following irrigation  differential diagnosis: bladder or prostate mass 

IVP shows masslike filling defect outlined by excretion contrast in the bladder carcinoma. DDxtumor, blood clot and fungus ball

Non contrast CT scan of the pelvis shows focal infiltrative thickening of the posterolateral bladder wall (arrows)

Bladder Diverticula

  Contrast enhanced CT scan of the pelvis shows marked infiltrating mass thickening the bladder wall and obstructing both ureters (arrows) resulting in bilateral hydroureter and hydronephrosis

ultrasound shows a large outpouching of the bladder wall and mucosa projecting from the lumen of the bladder. This diverticulum was in close proximity to the ureteral entrance into the bladder resulting in a particular type of bladder known as a Hutch diverticulum

Case 2

contrast enhanced CT of pelvis shows a small diverticulum projecting from the left lateral wall of the bladder (arrow)

Cystocele

plain film radiograph of the pelvis shows an air lucency in the bladder (arrows) in the same patient as above

Case 6

  

as focal herniations of the urothelium and submucosa cystoceles usually occur in the setting of chronic elevation of intravesical pressure they tend to occur next to ureteral orifices, and occur where small outpouchings of mucosa evaginate between hypertrophied detrusor muscle bundles, but do not extend past the bladder wall cystoceles constitute an important cause of urinary stasis, ureteral obstruction, and vesicoureteral reflux

Bladder Fistulas

Emphysematous Cystitis
  a rare form of bacterial cystitis that occurs in patients with poorly controlled diabetes E. coli is the most common pathogen and urinary stasis is a common feature

Bladder Stones

 

the most common causes of intravesical air include bladder catheterization or instrumentation vesicoenteric fistulas may be difficult to image- only 30-60 % are seen with cystography and barium enema iatrogenic causes, diverticulitis, carcinoma, and regional enteritis or Crohn s disease may lead to vesicoenteric fistulas

unenhanced CT scan of the pelvis in patient with hematuria shows stone material layering in the dependent portion of the bladder

unenhanced CT scan of the pelvis (bone windows on the left and soft tissue windows on right) shows laminated stone in the dependent portion of the bladder. There are also stones in the proximal urethra (arrows)