Imaging of the Genitourinary Tract

Imaging Modalities
• Conventional non contrast
– Plain X-Ray
• Conventional with contrast
– Intravenous pyelography
– Antegrade pyelography
– Retrograde Pyelography
– Retrgograde Cystography
– Retrograde Urethrography
– Cystourethrography
• Bipolar cystourethrography
• Voiding Cystourethrography
• Retrograde cystourehtrography
• Non-conventional
– Ultrasound
– Computed Tomography Scan
– Digital Substraction Angiography (DSA)
– Nuclear Medicine (Scintigraphy)
– Magnetic Resonance Imaging (MRI)
 Kidneys

Position of kidneys:
R: L1-L3
L: T12-L3
Long axis of the kidneys is directed downward and outward, parallel to the
lateral border of the psoas muscles
Ureter
Urinary Bladder
Urethra
 Plain Photo Abdomen (KUB)
or BNO
• Indication:
– Renal opaque calculi,
– Preparation for IVU
– Check placement of
catheters/stents/drains/foreign bodies
• Contraindication: none
• Technique: supine position
 Plain photo abdomen
• KUB
• All exposures at end
of expiration for any
urinary system study
• The Last 2 Ribs
• All Lumber And Sacral
Vertebrae
• Psoas Muscles
• Symphysis Pubis
 Plain X-ray film
• Renal shadow
• Gastrointestinal tract shadow
• Calcification or radiopaque shadow
• Psoas shadow
• Bone
 IVU (dulu IVP)
1. Suspected congenital anomaly
2. Renal Tumor
3. Renal colic
4. Persistent urinary tract infection
5. Renal Trauma

Indications
 Preparation

• After midnight: Nil Per Os (“puasa” + 8 hours)

• Bowel cleansing
• Clear liquid diet
• Don’t talk to much and smoking
• Empty bladder
• Free from contrast agent hypersensitivity
 Contrast Agent and Adverse Reactions
Complications Crucial not to leave pt alone for first
5 minutes after injection!
1 . Immediate
• Minor: Nausea, vomiting, arm pain, and headach
• Sever allergic: Erythema, urticaria, facial or glottic
edema.
Treatment: antihistamines, steroids and/or epinephrine.
• Chemotoxic or idiosyncratic reactions: (most serious)
Include: convulsions, pulmonary edema, cardiovascular
collapse, thrombosis, cardiac arrest. 1 of every 7,500
• The mortality rate for contrast administration, 1:100,000
2. Delayed
Nephrotoxicity: Patients with diabetic nephropathy,
creatinine levels are >3 mg/dl. This nephrotoxicity is
usually reversible.
 IVU procedure
1. Preliminary (Plain photo)
2. Immediate
3. 5 minute
4. Abdominal compression
5. Release
6. Post micturation
 Preliminary Film (Foto I)
• Precontrast KUB
radiograph.
– To demonstrate
opacities that may lie
within the urinary tract.
– To check abdominal
preparation, positioning
and exposure factor.
– Additional radiograph-
expiration or oblique of
the renal areas to • (All exposures at end
determine the position of expiration for any
of any opacities lie urinary system study)
within the urinary tract.
 Immediate film (Foto II)
• 1-3 min post contrast radiograph
collimated to the kidneys.
– To demonstrate the nephrogram phase.
– The renal parenchyma opacified by the
contrast in the renal tubules.
 5 minute film (Foto III)
• 5 min post contrast KUB radiograph.
– To determine if excretion is symmetrical or
– a further dose of contrast is required if the
opacification is poor.
• Abdominal compression is then applied if
no contraindication.
 Abdominal compression
• Contraindications:
– Evidence of obstruction on 5 minute image
– Abdominal mass
– Abdominal aortic aneurysm
– Recent abdominal surgery
– Severe abdominal pain
– Suspected urinary tract trauma
 Compression Film (Foto IV)
• A 15 min post contrast
collimated to the kidneys.
– To demonstrate
distended collecting
systems and proximal
ureters.
- effectively produces
partial ureteric
obstruction
- Improved calyceal detail
and more reliable ureteric
opacification upon release
of compression.
 Collecting system dilatation. Fifteen-
minute urographic image demonstrates a
standing column of contrast material from
the ureteropelvic junction to the
ureterovesical junction on the right, a
finding that is associated with mild
collecting system dilatation. A stone is
impacted at the ureterovesical junction
 Release film (Foto V-VII)
• A 30 min post contrast KUB radiograph
following release of compression.
To demonstrate the entire urinary tract
particularly the lower ureters.
• Additional radiograph - prone or upright
KUB when the lower ureters are not seen
adequately.
Post Micturation Film (Foto VIII)
• Post micturation KUB radiograph.
To demonstrate complete bladder
empting and any hold-up of contrast in
the collecting system.
• Persistence dilatation on post void image
suggest obstruction and decompression
indicates physiologic distension.
• Preliminary radiograph
Evaluation of IVU
– Gas, mass, stones, bones
– Renal shadows- size, axis,
calcification
– Course of ureter
• Immediate film
(nephrogram)
– Size, shape, symmetry,
contour
• Pyelogram
– Calices, ureters, urinary
bladder
• Batu pelvis
• (luscent pd
• Pelvis kanan)
-year-old man with
hematuria due to
transitional cell carcinoma
of bladder with ureteric
extension. Excretory
urogram shows large filling
defect (arrowhead) in
bladder that may be
explained by blood clot.

Read More:
http://www.ajronline.org/doi
/full/10.2214/AJR.10.4198
 Pyelography
Antegrade pyelography (APG)
• Outline the pelvicalyceal system and
ureteric anatomy
• Contrast is injected into the PC system
and outline the PC and ureter
Retrograde pyelography (RPG)
• Requires cystoscopy, placement of the
catheter to the distal part of ureter
 Antegrade pyelography (APG)
• Indications:
– Anatomic evaluation of pelvocalyceal
system
– Ureteric drainage for evaluate
• urine leak,
• post-percutanea nephrostomy
• residual stones
• site of ureteric obstruction
• ureteral fistulas
• Technique:
– Under flouroscopy
– Via catheter nephrostomy with using
contras media
– Supine position
 Retrograde Urography
• Indications:
– Hematuria,
– Contrast sensitivity,
– Suboptimal IVU,
– Needs cystoscopy
• Technique:
– Under fluoroscopy
– Contrast injected
directly into
pelvicaliceal system
via cathethers from
urethrae
– Supine positions
Cystography
 Cystography
• Indications:
– Vesicoureteral reflux
(backward flow of urine into
ureters)
– Recurrent lower urinary
tract infection
– Neurogenic bladder:
(dysfunction due to disease
of central nervous system or
peripheral nerves) Bladder
trauma
– Prostate enlargement
– Lower urinary tract fistulae
– Urethral stricture
– Posterior urethral valves
(obstructive congenital defect of
the male urethra)
 Cystography technique
• Technique:
– Contrast administration usually performed
retrograde via catheter urethra,
– Catheter cystostomy
– IVU (excretory cystography)
• Cystography Routine Series
– Scout view
– filled AP
– both obliques
– Lateral
– Voiding
– post-void
Excretory Cystogram (IVU) Retrograde Cystogram
 Urethrography
• Indications:
– To diagnose urethral stricture
– To evaluate urethra after trauma
• Technique:
– Urethra may be visualised as part of MCU
(descending) or ascending urethrogram
– Ascending urethrogramtip of catheter is in
the fossa of navicular.
– Spot film is taken when contrast is injected
Normal retrograde urethrogram
Retrograde urethrogram demonstrates a less common

type II urethral disruption. Extravasation of contrast

material
Straddle injury. Retrograde urethrogram shows
a type5 urethral injury with extravasation of
contrast material from the distal bulbous
urethra.
 Cystourethrography
• Static Cystourethrography=
“Retrograde
Cystourethrography”=“Cystourethrography”
• Bipolar Cystourethrography
• Voiding Cystourethrogram (VCUG)
 Cystourethrography
• Indications:
– Evaluate bladder lesion, rupture, leak, post
trauma/surgery bladder
integrity/anastomose/fistulas
• Technique:
– Scout,
– Fill bladder with 200-400 mL via urethrae syringe
or tip of catheter is in the fossa of navicular.
– A/P and obliques (shows extravasation posterior
to bladder),
– Post-drainage film
 Cystourethrography
• Technique: • Technique:
– AP Oblique Projection - – AP Projection (maybe obliques)
RPO/LPO – Bladder can be filled and patient
void for antegrade studies
– Patient is supine, rotated 35 – Cassette should be centered as
- 40 degrees for cystography
– Urethral syringe (or Brodney – Abduct thighs to prevent
clamp?) is used to introduce superimposition of bone or soft
tissue
contrast images are obtained
as contrast is injected
– Entire urethra must be
visualized
– Bladder can be filled to
obtain antegrade voiding
study

Male Female
Cystourethrography
Conventional cystogram

demonstrating

an intraperitoneal blad

der rupture.
intraperitoneal

bladder rupture.
Micturating cystourethrogram(MCU)/
Voiding Cystourethrogram (VCUG)
Functional and anatomic evaluation of bladder
Indication:
1. To detect vesicoureteric reflux who have recurrent
infection
2. Bladder rupture
3. Demonstrate posterior urethral valve
4. Ureterocele,
5. Dysfunctional voiding
6. Urethral strictures
7. Bladder/urethral diverticula
 Micturating cystourethrogram(MCU)/
Voiding Cystourethrogram (VCUG)
• Scout
• Pediatric: 5 or 8 F feeding tube, fill bladder with contrast
(age +2 x 30). Mainly for peadiatric patient
• Adult: standard catheter
• Filling the bladder with contrast introduced via urethral
catheter
• Film during filling- bladder pathology, early reflux
• Films during void- reflux, urethral abnormality
• Oblique- evaluate grade 1 reflux, males
• Post-void film
MCU
• A voiding
cystourethrogram (VCUG)
of a patient with grade III
vesicoureteral reflux
(VUR). Note that the
contrast flows up the
ureter and into the renal
pelvis. The calyces are
sharp
• This is an example of
grade V
vesicoureteral reflux
(VUR). Note the
dilated renal pelvis
and calyces. The
ureter also is dilated
and tortuous.
• This is bilateral
vesicoureteral reflux
(VUR)
 Ultrasound
Indication Technique
1. Renal mass A 3.5 transducer is
2. Haematuria generally used to
3. Flank pain scan the adult kidney
4. Blood urea elevation Liver and spleen act as
acoustic window for
5. Poor non functioning evaluation R and L
kidney on IVU kidneys respectively
6. Biopsy / Patient position:
interventional Supine, decubitus or
guidance prone
Ultrasound of Right Kidney
 Ultrasound of Kidneys

NORMAL STUDY
DILATED RENAL
PELVIS
• The parenchyma is
relatively normal in
thickness.
• The dilation of the
collecting system
extends from the
renal pelvis to the
calyces.
 Computed tomography
• Giving predominantly
anatomical
information
• Used when US
finding is inconclusive
• Staging of tumor
• Renal trauma
• Renal artery stenosis
• Calculi / obstructive
uropathy
Emphysematous pyelonephritis.
45-year-old man with
obstructing calculus in
distal part of left ureter.
Coronal reformation of
unenhanced CT scan
shows hydronephrosis
and hydroureter on left.
Calculus (arrowhead) is
in distal ureter. Extensive
streak artifact from left
total hip replacement is
evident.

Read More:
http://www.ajronline.org/d
oi/full/10.2214/AJR.10.41
98
74-year-old woman
with left-sided renal
cell carcinoma.
Nephrographic phase
CT scan shows avid
peripheral
enhancement with
central
hypoattenuation
(arrowhead)
suggesting necrosis.

Read More:
http://www.ajronline.or
g/doi/full/10.2214/AJR
.10.4198
Cystic renal cell carcinoma.
RCC with inferior vena cava
invasion
 MRI
• Anatomical information
• When US or CT is inconclusive
• MRA: for renal artery stenosis
• Multiplanar imaging – sag, coronal and
axial
• Time consuming / expensive
Large right renal cell carcinoma with renal vein
and inferior vena cava invasion.

• T2-weighted axial
MRI
• Dynamic gadolinium-enhanced magnetic
resonance angiogram (MRA) shows normal
renal arteries.
Renal Angiography
 Nuclear Scintigraphy
• Physiologic and anatomic info
• Renograph:
– Non-imaging (Ulin Hospital)
– With imaging (Gamma camera)
• Radioisotop+Radiofarmaka
– TC-99 m (t ½= 6 hrs)
– MAG3- cleared by tubular secretion, no glomerular
infiltration- evaluate renal function and renal
plasma flow
– DTPA- glomerular filtration- evaluate obstruction
and renal function
– DMSA- cleared by filtration and secretion- renal
cortical image
THANKS YOU