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Genitourinary Radiology

Prepared for the UBC Undergraduate Medical Program
2007
Contributors
Stephen Ho, SavvasNicolaou, J ohn Aldrich, Leo Mok
Main Index
Imaging techniques
Patient preparation
Normal anatomy
Pathological conditions
Contents
Patient preparation
Normal anatomy
4.4.2 Renal colic
4.4.3 Urosepsis
4.4.4 Renal mass
4.4.5 Acute/chronic renal
failure
4.4.6 Trauma
Renal and uretericcalculi
Hydronephrosis
Renal cyst versus renal carcinoma
Additional Pathological Conditions
Microscopic hematuria
Transitional cell carcinoma
Pathological
conditions
Imaging techniques
Choosing the most appropriate test
Plain radiographs and tomograms
Retrograde pyelogram
Intravenous pyelogram(IVP)
Ultrasound (US)
Computed tomography(CT)
Nuclear medicine renogram
Magnetic resonance imaging (MRI)
Angiography
1.Imaging Techniques
Choosing the most appropriate test
Plain radiographs and tomograms
Retrograde pyelogram
Intravenous pyelogram(IVP)
Ultrasound (US)
Computed tomography (CT)
Nuclear medicine renogram
Magnetic resonance imaging (MRI)
Angiography
Choosing the most appropriate test
For imaging GU function
IVP
Nuclear renogram
For imaging GU anatomy
Plain radiographs
IVP, retrograde pyelogram
US, CT, MRI
Plain Radiographs and Tomography
Indications
Screening for
urinary calculi
Diffuse abdominal pain
Essential part of IVP
Plain Radiographs and
Tomography
Retrograde Pyelogram
Performed by
urologist in OR
Requires general
anaesthetic
Excellent detail
of urinary
collecting system
Intravenous Pyelogram(IVP)
Demonstrates renal, ureteral and bladder
anatomy
Gross estimate of function
Ionizing radiation
Requires IV contrast
Patient prep
IVP
Consists of a KUB and a series of post-contrast
injection film
1) Pre-contrast scout (KUB) film
2) Nephrogramphase
- typically at 1 minute post-contrast injection
3) Subsequent post-contrast injection films
Intravenous Pyelogram(IVP)
Preliminary film
30 second film
Intravenous Pyelogram(IVP)
5 minute film
Renal tomogram
Ureteral compression
applied
Intravenous Pyelogram(IVP)
Film after ureteral compression released
Ultrasound
Excellent renal and bladder anatomy
Can assess blood flow
Useful in helping differentiate between solid and
cystic masses
Can use TRUS to evaluate the prostate or guide
biopsies
Poor ureteral anatomy
No functional information
Ultrasound
Ultrasound
Computed Tomography (CT)
Used selectively for specific indications
Excellent anatomic detail
Ionizing radiation
Usually requires IV contrast
Computed Tomography (CT)
CT anatomy
Magnetic Resonance (MRI)
Used selectively for specific indications
Excellent anatomic detail of kidneys
Safely performed in renal failure
No ionizing radiation
Magnetic Resonance (MRI)
Nuclear Medicine
Excellent physiologic imaging tool
Accurately measures renal function
Poor anatomic detail
Ionizing radiation
Nuclear Medicine
Two types of renal scans:
1) renogram: used to quantitaterenal function
2) morphological study: examines renal anatomy
Angiography
GU hemorrhage
Renal artery stenosis
Partial nephrectomy
Significant risk of complications
Very expensive
Angiography
Patient Preparation
Renal CTA
Patient to drink 750 cc water or juice 1 hour prior to CT
Pelvic ultrasound
Patient must have a full bladder for this exam
Finish drinking 32 oz. (approximately 4 glasses) of water
2 hours prior
Do not void after drinking
Patient Preparation
MRI
Hair must be dry
Do not wear any jewelry
Own clothing free of metals (zipper, hooks, buttons)
No fasting or special diets needed
Patients with colds or coughs will be rescheduled (due to
motion with sniffing or clearing)
Patient Preparation
IVP
- clear fluids the day before
- NPO after midnight the day before
- cathartics the evening before
Normal Anatomy
Identify:
Kidney
Renal pelvis
Renal calyx
Ureter
Bladder
Normal Anatomy
Kidney
Bladder
Aorta
Renal arteries
Identify:
Pathological Conditions
Renal and uretericcalculi
Hydronephrosis
Renal cyst versus renal carcinoma
Additional Pathological Conditions
Microscopic hematuria
Transitional cell carcinoma
Renal colic
Urosepsis
Renal mass
Acute/chronic renal failure
Trauma
Renal Calculi
Renal Calculus - US
Hydronephrosis
Approach to Renal Masses
Most renal masses are simple cysts
Use US to characterize the mass
simple cyst : STOP
solid mass or atypical cyst: CT
US and CT characterize > 90% of masses > 1.5 cm
Biopsy is rarely warranted
Renal Mass
Simple cyst on ultrasound
Renal Masses
Initial investigation should be US
Cysts: uniformly hypoechoic, good through
transmission, imperceptible wall
Tumours: solid, contour deforming
Renal Mass
Left renal mass on IVP
Renal Cysts
- US will determine if the lesion
is cystic or solid
- 2 Types of Renal Cysts:
1) Simple: spherical, echo-free
fluid collection within a thin
surrounding wall and will show
good sound wave transmission
2) Complicated: will show the
presence of echoswithin the cyst,
will have a thick wall, and/or show
calcification in the wall
Renal Carcinoma
- if US indicates that the mass is
solid, CT with IV contrast can
characterize the tumour in greater
detail – delineate extent, show
the degree of vascularity,
presence/absence of necrotic
centre, presence/absence of local
invasion of adjacent structures
Additional Pathological
Conditions
Microscopic hematuria
Transitional cell carcinoma
Renal colic
Urosepsis
Renal mass
Acute/chronic renal failure
Trauma
Microscopic Hematuria
Abnormality in 88% of patients
9% have GU tract malignancy
Etiologies: infections, stones, tumours
Rule out infection with clinical/lab data
Use imaging to evaluate for structural
abnormality (stone, mass)
Microscopic Hematuria
Acceptable imaging strategies
1) KUB to identify stones
- Renal US to identify mass
- Cystoscopy and Retrograde if KUB and US normal
2) IVP
- Renal US and Cystoscopy if IVP normal
Microscopic Hematuria
Microscopic Hematuria
Ultrasound of a right renal calculus
Microscopic Hematuria
Bladder Calculi
Transitional Cell Carcinoma
Most common malignancy of ureter and
bladder
<10% of renal malignancies
Typically present with gross hematuria
CT for staging and surgical planning
Treatment: radical nephrectomy
Transitional Cell Carcinoma
IVP and retrograde pyelogramTCC proximal left ureter
Transitional Cell Carcinoma
IVP and retrograde pyelogramTCC proximal left ureter
Transitional Cell Carcinoma
IVP and pelvic CT – large TCC of bladder obstructing right ureter
Transitional Cell Carcinoma
Small TCC of bladder in patient with hematuria
Transitional Cell Carcinoma
Bladder TCC in two patients
Renal Colic
Questions to ask:
Are urinary stones present?
If so, what is the level and size?
Is obstructions present?
If so, what is the level and severity
Is urgent intervention required?
Factors include: urosepsis, solitary kidney, severe pain
Treatment: percutaneous nephrostomy or ureteric stent
Renal Colic
Preliminary film in patient with right renal colic
Renal Colic
10 minutes
Delayed function
on right side
25 hours
Persistent nephrogram
29 hours
Dilated ureter to stone
Renal Colic
Radiopaque stone distal ureter
Renal Colic
Radiolucent uric acid stones
Renal Stones
Management dictated by size and location of
stones
ESWL monotherapy
Ureteroscopy
Percutaneousdebulkigand ESWL
Surgery is rarely necessary
Urosepsis
Establish a clinical diagnosis:
pyelonephritis, cystitis, prostatitis
Urosepsisand an obstructed ureter is a
urologic emergency!
Renal US performed to rule out:
Renal obstruction
Renal or perirenal abscess
Urosepsis
Left pyonephrosis Right UPJ stone causing
hydronephrosis
Urosepsis
Ultrasound showing a right pyonephrosis and obstructing UPJ stone
Urosepsis
Percutaneous nephrostomy
for decompression 2 weeks post ESWL
Renal Mass
Most renal masses are simple cysts
Use US to characterize the mass
simple cyst : STOP
solid mass or atypical cyst: CT
US and CT characterize > 90% of masses > 1.5 cm
Biopsy is rarely warranted
Renal Mass
Left renal mass on IVP Simple cyst on ultrasound
Renal Mass
Distortion of left pelicalyceal system in IVP
Renal Mass
Solid left renal mass in a patient with micro hematuria
Renal Mass
Renal Angiomyolipoma
Benign harmartomatoustumour comprised of
fat, smooth muscle and vessels
Usually asymptomatic
Occasionally present with hemorrhage when
large or multiple
Fat detected in 96% by CT
Renal Mass
Renal Adenocarcinoma
90% of all renal malignancies
15-30% metastaticat diagnosis
Hematogenousand lymphatic spread
10% have venous invasion (renal vein or IVC)
Treatment:
Radical nephrectomy
Partial nephrectomy
Renal Mass
Renal Adenocarcinoma
Appropriate imaging workup:
Chest X-ray: pulmonary metastases
CT abdomen: local invasion, lymphadenopathy,
venous extension
MRI abdomen: renal failure, contrast allergy
Acute and Chronic Renal Failure
Clinical catergories
Prerenal (dehydration, shock, cardiac failure)
Renal (parenchyma, diabetes, GN, drugs, renovascular)
Postrenal (obstruction)
IV contrast contraindicated if creatinine>200 mmol/d
Use ultrasound to assess:
Renal size
Parenchymal thickness
Ultrasound guided renal biopsy to establish diagnosis
Acute and Chronic Renal Failure
Hydronephrosis post-renal Atropic, echogenic kidney
Medical renal disease
GU Trauma
Penetrating trauma (gunshot, stab)
Unstable
Surgery or angiography
Stable
CT
GU Trauma
GU Trauma
Blunt Trauma (MVA, fall, crush)
Unstable: surgery or angiography
Stable: CT abdomen +cystogram
Gross hematuria
Micro hematuria+ shock
Major visceral injury: no imaging necessary if
Micro hematuria, no shock
No other visceral injuries
GU Trauma
Grade 5 injury: thrombosed renal artery
GU Trauma
Grade 4 injury: deep lacerations with perirenal hemorrhage
GU Trauma
Extraperitoneal bladder rupture
Intraperitoneal bladder rupture
GU Trauma
Normal retrograde
urethrogram
Traumatic rupture of bulbous urethra