Introduction to Imaging

Urinary System

Koa AJ
 Organs
• Kidney
• Ureter
• Urinary bladder
 Modalities for imaging the urinary
system
• Ultrasound
• Plain X-ray
• Contrast study: intravenous urogram
• CT Scan
Ultrasound
 Cortex
Medulla
Medulla and cortex can
be differentiated on
ultrasound as medulla is
darker (more
hypoechoic)

Renal sinus

“Slices” of kidney in longitudinal plane

 Ultrasound application
• First modality to use when evaluating
urinary diseases
• Obstruction / hydronephrosis
• Calculus disease
• Evaluate renal size
• Suspected renal tumor or cysts
• To evaluate blood flow within the renal
arteries or veins (e.g. renal arterial
stenosis / renal vein thrombosis)
 • Strengths:
• Readily available
• Cheap
• Fast
• No ionizing radiation
• Weaknesses:
• Body habitus can be limiting
factor
• Operator dependant
Normal

Example of hydronephrotic kidney

Renal calculus on ultrasound

Echogenic focus
Posterior shadowing
Plain X-ray
• Renal outlines are usually visible
due to presence of perinephric fat
• Bipolar length usually up to 13cm
• Notice diverging lower pole in
kidneys which are normally
orientated. Loss of this
configuration indicates
malrotation of kidneys
 Plain X-ray
• Indication:
– Urolithiasis.
• Strengths:
– Readily available
– Cheap
• Weaknesses:
– Not sensitive; not specific
– Ionizing radiation
 Urolithiasis
• Calculus in the urinary collecting system
• 90% radio-opaque
• Uric acid and xanthine stones radiolucent
Right renal calculus
 Staghorn Calculus

Ureteric Calculus
Bladder calculus
Urethral Calculus
Sometimes calcification is within the
renal parenchyma
Contrasted Studies: Intravenous
Urogram (IVU)
 Contrast Media
• If the two organs of similar densities, it is
not possible to distinguish them on a
radiograph.
• Densities within hollowed structures (e.g.
urinary system or blood vessels) can be
artificially increased with use of contrast
media.
• This difference in densities will allow
visualization of these hollowed structure.
Without contrast
With contrast
Iodinated contrast media
 IVU
• Sequences:
1. Prelim/plain: for radio-opaque calculus
2. 5 minute KUB: for symmetry of excretion
3. Compression (immediately after review of 5
minute KUB): for pelvicalyceal evaluation
4. Release (15 minutes after contrast
injection): for assessment of ureters
5. Post-micturation: for assessment of urinary
bladder and residual contrast in
pelvicalyceal system and ureters
 IVU
• To identify obstructive uropathy, filling
defects, distortion of normal anatomy &
function (non qualitative)
• Injected iodinated contrast media →
excreted via kidneys allowing visualisation
of kidneys, ureters and bladder
IVU

Minor calyx

Major calyx
Renal papilla

Renal pelvis
Control film

For radio-opaque stones

1
5 minute film

For nephrogram & excretion

2
Head down / compressed view

For nephrogram & excretion

3
Release

For the entire ureter and bladder assessment

4
Post-micturating

For standing column / stagnant of contrast

Within the collecting system and bladder
emptying

5
 IVU
• Strengths:
– Readily available
– Cheap
• Weaknesses:
– Iodinated contrast media is used → may result in
allergic reaction, renal damage and other contrast
related complications
– Meticulous bowel preparation is needed
– Limited sensitivity and specificity
– Ionizing radiation
 CT Scan
• Cross sectional imaging.
• Utilizes X-ray
• Demonstrate relationship with surrounding
structures
 CT applications
• Trauma
• Tumor
• Calculus (particularly ureteric calculus)
Grade III renal laceration
Left renal tumor: angiomyolipoma
 CT
• Strengths:
– Fast
– Informative
• Weaknesses:
– X-ray
– Expensive
– Iodinated contrast media
End