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KIDNEY URETER BLADDER  Sharp and pointed

 Dark area around collecting system duct


to fat in hilum
 KUB is variously called a plain film or scout  Course or ureters
film. It is done primarily to IVP  Anterior to psoas at L4-L5
 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 peri-renal abscess

Scout Film

 Any calcification over kidney, ureters,


bladder regions and the rest of the Bladder
abdomen
 Skeleton  Size
 Spine  Displacement and extrinsic pressure
 Transverse processes  Lumen for filling defects
 Pelvis
 Soft Tissue
o Psoas shadows
o Margins of kidneys
o Bladder distention

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
Limitations

 Contrast complications
Disadvantages  May aggravate an existing urinary tract
infection or triggering one from the
catheterization
 Labor and time intensive – it may take up
to 6 hours to complete in the severe
Utility/Indications
obstruction
 It requires placement of an intravenous
 Children with urinary tract infections
line
 Reflux is detected if contrast is seen to
 Requires a bowel preparation for optimal
flow in retrograde fashion up the ureters
results
from the bladder
 Involves intravenous injection of
 Pelvic trauma where rupture of the
potentially allergic and mildly nephrotoxic
bladder or urethra is suspected
contrast
o If the bladder is ruptured,
Retrograde Pyelogram extravasations of contrast will be
seen outside the bladder in the
pelvis or abdomen
• Like IVP, retrograde pyelography relies on
o If urethra is ruptured, there is
contrast medium to produce detailed x-ray extravasations into the perineum
images of the urinary tract
How it is done…
Images of the urinary tract
 Avoiding cystourethrogam is performed by
Indications inserting a catheter into the urethra
 Contrast material is then instilled into the
 Commonly performed when IVP produces bladder through the catheter
an inadequate picture. Useful to study  x-rays are taken before, during and after
urinary tract obstruction when further filling of the bladder
calcification of nature of utreteral  when the bladder is full, the catheter is
obstruction is required removed
 It also complements cytoscopy while  while the patient voids, additional x-rays
investigating a patient with hematuria or are taken
recurrent or suspected cancer
 Detects small lesions in the collecting
system. E.g. transitional cell carcinoma
• Hematuria
• Local staging of cancer to allow definitive
surgical management if needed
• Renal artery and vein evaluation

Disadvantages

• 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
Limitations

 Insertion of the catheter is painful


 While 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

Utility

 Helpful in defining renal, bladder and


prostate anatomy
 It is the test of choice to exclude urinary • MRI is as good as CT or better in
tract obstruction characterizing lesions of kidney and
 US can, in the majority of cases diagnose prostate
hydronephrosis • Because of its ability to show soft tissue
 Good for evaluating kidney size sin exquisite detail, MRI can detect
 Good to distinguish between cysts and disease and evaluate renal vasculature
solid mass and inferior vena cava
 Good to localize kidney for biopsy • MRI can delineate a cyst from a solid mass
• It can identify the spread of kidney cancer
Indication into the renal vein, IVC and prerenal area
(staging)
• 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
 occur in approximately 1 in every 4000
children
 females are affected 4-7 times more often
than males

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
Disadvantages
Case 2
• 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 3

Renal Agenesis
Case 1
 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

Ureterocele Bilateral Renal Agenesis


 a fatal anomaly
 congenital saccular dilatation of the  occurs in one per 3000 live births, and due
terminal portion of the ureter to oligohydramnios
 ectopic ureterocele enter the bladder, -these newborns present with Potter’s
typically arise from the upper pole moiety syndrome-low set ears, broad flat nose,
of a duplicated collecting system
prominent skin folds below the lower eyelids,
pulmonary hypoplasia and pneumothorax

Case 4

Horseshoe Kidney
 occurs in one of every 400 livebirths
 most common renal anomaly
Multicystic Dysplastic Kidney (MCDK)  males are twice as likely to have the
 occurs as a result of inadequate induction anomaly as females
of maturation of the metanephric  associations include UPJ obstruction,
blastema by the ureteric bud duplication anomalies and stone formation
due to abnormal kidney geometry and
2 Types urine stasis
a. Pelvoinfundibular MCDK- randomly
distributed, non-communicating cysts Pelvic Kidney
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  premature arrest of cranial ascent of the
kidney
Medullary Sponge Kidney  a 3:2 male-to-female predominance
 also known as benign renal tubular  bilateral pelvic kidneys may fuse, forming
ectasia, it is a cystic dilatation of the a discoid single kidney known as a
collecting tubules in 1 or more renal pancake kidney
pyramid. Urine stasis in the collecting  major complications include:
tubules may lead to stone formation -trauma (due to decreased protection) and
within the ectatic tubules nephrolithiasis (due to altered geometry resulting
in urine stasis)
Case 5
 associated with other urinary tract
anomalies including:
-UPJ obstruction, vesicoureteral reflux, and
decreased function

Case 1

Case 6
density cysts
(>20 HU), non-
enhancing
III M Renal-sparing
ultiloculated, suregery
hemorrhagic,
dense
calcifications,
nonenhancing
solid
component
IV Marginal Radical
irregularity, nephrectomy
enhancing
solid
component

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

Renal Cysts
 50 % of the population older than 50 years
 the cyst shows high signal on T1 and T2-
 most are asymptomatic, though a large
weighted images suggesting it is more
cyst can cause discomfort and
complex perhaps from hemorrhage or
hypertension
from proteinaceous contents
 a ruptured cysts may result in hematuria,
an infected cyst results in fever Bosniak II Lesions
 both infected cysts and hemorrhagic cysts
are non-simple by imaging

Bosniak Classification of Renal Cysts by CT

Classification Features Managament


I Simple Cyst Non-operative
II Septated, Non-operative
minimal
calcium
described as
“egg shell”
thin, high-
 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

 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 III Cyst


 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

Case 2

 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


 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
Autosomal Dominant Polycystic Kidney
and IVC
Disease (ADPKD)
 US: small tumors are generally
 an autosomal dominant disease hypoechoic, large tumors hyperechoic
 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

 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
 55 y/o male presented with palpable mass thrombus in the IVC (arrow) in an
in the right flank with pain and hematuria advanced renal cell carcinoma

Renal Cell Carcinoma Robsons Classification


 also known as renal adenocarcinoma,
hypernephroma, clear cell carcinoma, and Stage I
malignant nephroma  (50 % 5-year survival) confined to renal
 accounts for 90-95 % of primary renal parenchyma, < 7 cm
cancers Stage II
 50-60 years  (50 %) spread outside of renal capsule,
but confined by Gerota’s fascia, or >7 cm
 patients present with hematuria (50 %),
Stage III (35 %)
flank pain (40 %), palpable mass (35 %),
weight loss (25 %), and paraneoplastic  venous tumor extension to renal vein,
syndrome infradiaphragmatic or supradiaphragmatic
IVC
 regional lymph node metastases
 venous extension and regional lymph intrarenal abscess (arrows) with
node metastases perinephric extension
Stage IV (15 %)
 direct invasion beyond Gerota’s fascia Renal Abscess
 distant metastases  usually a complication of untreated
 late post-nephrectomy metastases occur pyelonephritis
in 10 %  caused by ascending infection from gram
negatives organisms (E. coli)
 long term survival is possible with  predisposing factors include stone
untreated tumor disease, diabetes, or AIDs
 complications include retroperitoneal
Angiomyolipomas spread and renocolic fistula

Case 1

 are hamartomas containing fat, smooth


muscle, and blood vessels
 most are asymptomatic, but may
hemorrhage if large Chronic Medical Renal Disease
 larger symptomatic lesions (>4 cm) can  a small right kidney with uniformly thin
be resected or embolized renal cortex and marked increased cortical
 80 % of patients with tuberous sclerosis echogenicity all points to a chronic insult
have AML, usually multiple lesions to this kidney. L= liver
bilaterally
 CT scan: fat, appearing as a hypodense Case 2
 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

 Patient had fever, flank pain,


costovertebral tenderness
 CECT scan through the kidneys in a
patient with pyelonephritis and persistent Pyelonephritis
fever despite antibodies shows left  a bacterial infection of the renal
intrarenal fluid collection with areas of parenchyma and collecting system
poor or no enhancement consistent with
 a clinical diagnosis based on fever, flank D2: regional lymphadenopathy (N4), distant
pain, costovertebral angle tenderness, and metastases (M1)
urinary tract infection

Case 3

 IVP shows masslike filling defect outlined


by excretion contrast in the bladder
carcinoma. DDx- tumor, blood clot and
fungus ball
Bladder Carcinoma
 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  Non contrast CT scan of the pelvis shows
-rhabdomyosarcoma (in ages 2-6) focal infiltrative thickening of the
posterolateral bladder wall (arrows)
 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
 Contrast enhanced CT scan of the pelvis
shows marked infiltrating mass thickening
Jewett-Strong-Marshall Staging (TNM
the bladder wall and obstructing both
staging)
ureters (arrows) resulting in bilateral
hydroureter and hydronephrosis
0: carcinoma-in-situ (TIS) and noninvasive
papillary tumor (TA)
Case 2
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)
resulting in a particular type of bladder
known as a “Hutch” diverticulum

Cystitis
 an inflammation of part or the entire
urinary bladder wall  contrast enhanced CT of pelvis shows a
 common causes include: small diverticulum projecting from the left
-infection- E.coli, klebsiella, pseudomonas, lateral wall of the bladder (arrow)
schistosomiasis, also viral and fungal cause
-irritative or mechanical (such as an Cystocele
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
non-bladder 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
 as focal herniations of the urothelium and
 note bladder wall thickening in the left submucosa cystoceles
lateral bladder wall from radiation induced  usually occur in the setting of chronic
cystitis elevation of intravesical pressure
 a mass like lesion in the dependent  they tend to occur next to ureteral orifices,
portion of the bladder may represent a and occur where small outpouchings of
mass (arrows). However, this patient mucosa evaginate between hypertrophied
presented with gross hematuria which detrusor muscle bundles, but do not
resolved following irrigation extend past the bladder wall
 differential diagnosis: bladder or prostate  cystoceles constitute an important cause
mass of urinary stasis, ureteral obstruction, and
vesicoureteral reflux
Bladder Diverticula
Bladder Fistulas

 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
Bladder Stones

 the most common causes of intravesical


air include bladder catheterization or
instrumentation  unenhanced CT scan of the pelvis in
 vesicoenteric fistulas may be difficult to patient with hematuria shows stone
image- only 30-60 % are seen with material layering in the dependent portion
cystography and barium enema of the bladder
 iatrogenic causes, diverticulitis,
carcinoma, and regional enteritis or
Crohn’s disease may lead to vesicoenteric
fistulas

 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.
 plain film radiograph of the pelvis shows
There are also stones in the proximal
an air lucency in the bladder (arrows) in
urethra (arrows)
the same patient as above

Case 6

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