Pemeriksaan Penunjang Urologi

Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah
Imaging Modalities
Dr. Ferdi Stefiyan

IMAGING MODALITIES
• Plain films
• Cystography
• Retrograde Urethrography (RGU )
• Voiding Cystourethrography (VCUG)
• Urodynamic studies
• Ultrasonography (US)
• Computed tomography (CT)
• Magnetic resonance Imaging (MRI)
• Radionuclide imaging
BNO (Blass Nier Overzicht)

• Skin, Skeletal, Soft Tissue,
Stone
• Indication :
– Hematuria
– Passing stone
– Colicky pain
BNO-IVP
• Kidney Function (Secretion & excretion)
• Stone (location, size)
• Stone effect to kidney ( Hydronephrosis)
IVP
5 minute : fase renogram, 10 minute: pyelogram,

30 minute : contrast fill the PCS & ureter, Post Void
Hydroneprhosis
Ureter Injury
Excretory urography
demonstrating extravasation
in the upper right ureter
consequent to stab wound.
Note lack of contrast (arrow)
in the ureter below the site
of injury, indicating
complete ureteral
transection.
Bladder Stone
• Densely radiopaque
• May single or multiple
• Primer : stones form de novo in
the bladder
• Secondary : stones are either
from renal calculi which have
migrated, or from concretions
on foreign material (e.g urinary
catheters)
Urethrocystography
Retrograde Urethrography
• To evaluate the anterior and posterior urethra.
• Beneficial in demonstrating the total length of a urethral
stricture
• Demonstrates the anatomy of the urethra distal to a
stricture
• May be performed in the office or in the operating room
before performing visual internal urethrotomy or formal
urethroplasty.
Fulgham PF, Bishoff JT. Urinary tract imaging: basic principles. In: Kavoussi LR, Novick AC, Partin AW,
Peters CA, editors. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier Saunders; 2012. p. 99-111.
Retrograde Urethrography : Technique

• A plain film radiograph is obtained
• Position : slightly oblique, penis is placed on slight tension
• A small catheter may be inserted into the fossa navicularis
with the balloon inflated to 2 mL with sterile water
• Contrast is introduced via catheter-tipped syringe
• Alternatively, a penile clamp (e.g., Brodney clamp) may be
used to occlude the urethra around the catheter
Fulgham PF, Bishoff JT. Urinary tract imaging: basic principles. In: Kavoussi LR, Novick AC, Partin AW, Peters
CA, editors. Campbell-Walsh Urology. 10th ed. Philadelphia: Elsevier Saunders; 2012. p. 99-111.
Retrograde Urethrography : Indication

1. Evaluation of ureteral stricture disease
2. Assessment for foreign bodies
3. Evaluation of penile or urethral penetrating
trauma
4. Evaluation of traumatic gross hematuria
Retrograde Urethrogram
Urethra Rupture
Retrograme urethrogram shows complete disruption of posterior urethra

“Up-and-down-o-gram”
(bipolar urethrocystography)
• The patient is asked to attempt to void with the
bladder filled
• Ideally, the prostatic urethra should be visualized as
the bladder neck opens, enabling measurement of the
distance between the severed urethral ends
• Then retrograde urethrogram should be obtained
simultaneously
A B
A : bipolar urethrocystogram of posterior urethral disruption injury

B : postoperative normal urethral caliber
Bladder Rupture
Cystogram reveals extraperitoneal bladder rupture with extravasation

into scrotum
Ultrasound
KIDNEYS
• Common indications
– Evaluation of collecting system obstruction
– Evaluation of suspected or known nephrolithiasis
– Evaluation of cystic renal disease
– Detection of a renal or perirenal mass lesion
– Characterization of a renal mass lesion
– Guidance for diagnostic or therapeutic interventional
procedures
Normal Sonographic Appearance

Normal kidney: (A) Sagittal view showing cortex and hypoechoic pyramids
with bright central sinus echoes. (B) Transverse view at level of renal hilum

• The determination of renal size with Us is more
accurate than with intravenous urography
Acute pyelonephritis Appearance
Ultrasound of acute pyelonephritis. Arrows show abnormally echogenic and

swollen upper pole.
Acute renal abscess Appearance

Acute renal abscess.
Transverse ultrasound
image of the right kidney
demonstrates a poorly
marginated rounded
focal hypoechoic mass
(arrows) in the anterior
portion of the kidney.
Hydronephrosis
Typical ultrasound image of ureteropelvic junction obstruction, with dilated renal pelvis and infundibula
and calyces, including color Doppler images. Note, the ureter is not visualized in this image.
Kidney Stone
Stone shadow seen on ultrasound.
Presence of a shadow can not only
be used to improve confirmation
of stone visualization
Renal Cyst
Well-marginated anechoic lesion
with thin wals
Polycstic Kidney Disease

ULTRASOUND :
URINARY BLADDER
Common indications :
• Determination of the existence and rate of urine flow
through the vesicoureteric junction in patients with dilated
ureters
• Determination of pre- and post-void bladder volume
• Detection of bladder calculi or mass
• Detection and quantification of bladder wall thickening
• Guidance for diagnostic or therapeutic interventional
procedures

• The normal distended bladder is an anechoic
structure occupying the midline of the true pelvis.
• It has thin walls (less than 3 mm in the distended
state and 5-6 mm when nondistended),
• Transabdominal evaluation of the ureteral jets is
helpful to assess for any proximal obstruction. On
gray scale
ULTRASOUND :
PROSTATE
Common Indications
• To quantify prostate volume
• Assessment of a palpable nodule
• Evaluation of infertile patients
• Guided prostatic biopsy

• The normal prostate gland is shaped like a
pyramid and lies posteroinferior to the bladder
• The normal volume (weight) ranges from 20-25
ml.
• Prostatic volume can be calculated by using the
prolate ellipsoid formula (0.523 × length × width
× height).
Normal prostate.
Transabdominal axial
scan shows the
prostate (P) between
the bladder (UB) and
the rectum (R)
Prostate Enlargement
• Increase in the volume of the
prostate exceeding 30 mL
• Central gland is enlarged and is
hypoechoic or of mixed
echogenicity
• Calcification may be seen both
within the enlarged gland as well
as in the pseudocaplsule
(representing compressed
peripheral zone)
• Post-micturition residual volume
is typically elevated
Mass in Bladder
• Well-defined
• Isoechoic to
hyperechoic mass
attached to wall of
urinary bladdder
Bladder Stone
• Mobile
• Echogenic
• Shadow distally
• May be associated
with bladder wall
thickening due to
inflammation
Bladder Diverticulum
• Outpouching from
the bladder wall
• Resulting from
chronic bladder
outlet obstruction
Computed Tomography
• the kidney is a much better understood organ as

CT has enlarged the capacity to visualize the
genitourinary tract noninvasively
• The anatomical characteristics of the kidney and
perirenal region can be accurately and
consistently visualized.
NORMAL RENAL STRUCTURE AND

CT ANATOMY OF KIDNEYS
Transverse CT images obtained with a

multidetector row CT scanner showing the
normal anatomy progressing from superior
to inferior (A) the renal pelvis (B) upper
ureters (C) mid ureters and (D) distal ureters
NORMAL RENAL STRUCTURE AND

CT ANATOMY OF KIDNEYS
Axial CT scan showing

the normal prostate
as a homogeneous
well-marginated soft
tissue 2-4 cm in
length located
beneath the
symphysis pubis
anterior to the
rectum
Noncontrast CT
• Obtained to locate the kidneys, evaluate
urolithiasis, detect acute hematoma, and obtain
baseline density measurements of renal masses.
• Noncontrast CT is accepted as primary imaging to
detect urinary calculi.
Normal CT Nephrogram
Contrast-enhanced scan
of the kidney in the
corticomedullary (CM)
phase showing dense
cortical enhancement,
the renal cortex is
distinctly differentiated
from the unenhanced
medulla
(A) Noncontrast axial CT showing a large hypodense mass

with no differential density replacing the left kidney. (B
and C) The corticomedullary phase shows multiple
tortuous feeder vessels depicting tumor hypervascularity.
Thrombus is also seen in IVC – Wilm’s tumor
Multiplanar Reformation (MPR)
(A) Coronal MPR image demonstrating only a small segment of the left ureter in its mid portion (B)
Curved multiplanar reformation displaying a left ureteric calculus, the consequent hydronephrosis and
the entire dilated ureter proximal to it in a single image regardless of opacificaion
Volume Rendered Technique (VRT)
Volume rendering technique (VRT) displaying the entire urinary tract. This technique takes the
entirevolume of data and displays anatomic structures withdifferent levels of opacity/attenuation
MULTIDETECTOR CT UROGRAPHY
(MDCTU)
• Indication of CT Urography
– Calculi
– Renal tumors
– Urothelial tumors
– PUJ obstruction
– Congenital anomalies.
(MDCTU)
Calculi
• MDCT is the most sensitive and specific test for the
diagnosis of urinary tract calculi.
• also accurately determine the level of obstruction.
• Ability to exclude extraurinary pathologies that may
mimic calculi.
• Can also detect calculi in unusual positions such as in
calyceal divertculae
(MDCTU)
CT urogram using MIP technique (A) depicting a calculus at the pelviureteric junction on the right side
and a calculus in the proximal left ureter. There are backpressure changes on both sides. VRT image (B)
displaying the same
Staghorn Calculi CT
Coronal CT
reconsstruction of
horseshoe kidney with
bilateral staghorn
calcui. Note the
medial and inferior
position of the
horsehoe kidney
(MDCTU)
Noncontrast axial CT (A) showing a radiodensity at the right ureterovesical

junction (UV junction) s/o calculus. Curved MPR image after contrast opacification
(B) depicting the calculus at the right UV junction with proximal hydronephrosis
and hydroureter. CT urography using MIP (C) image showing the dilated
hydroureter and hydronephrosis proximal to the calculus. The normal nondilated
pelvicalyceal system and ureter is seen on the left side
(MDCTU)
Renal Tumors
• is an appropriate imaging test for the detection
and characterization of renal masses.
• MDCT urogram demonstrates not only the
pelvicalyceal system as in conventional urography
but also renal, perirenal and vascular tissues.
(MDCTU)
Contrast-enhanced axial CT scan: (A) showing an enhancing mass in the upper and
mid pole of the right kidney. CT urogram using volume rendering (B) showing
distortion of the calyces by the mass lesion. CT urogram using MIP technique (C)
showing splaying, distortion and amputation of the calyces on the right side –right
renal cell carcinoma
MDCT IN BLUNT RENAL TRAUMA
• MDCT involving fast volume scanning requires

less patient cooperation and creates fewer
artifacts
• The CMP (Corticomedullary phase) images are
best suited to visualize injury of the renal arteries
including nonocclusive ntimal injury of the main
renal artery and renal vein thrombosis.
(MDCTU)
Corticomedullary phase (A and B) of contrast enhanced CT depicting a large

hematoma replacing the left kidney with injury and pseudoaneurysm of the left
renal artery. 3-D CT angiogram, MIP technique in oblique axial plane (C) Depicting
the pseudoaneurysm
Renal Pelvis Laceration
Computed tomography showing right medial extravasation of contrast material in

a patient with a renal pelvis laceration.
UPJ obstruction
Noncontrast computed tomography of left ureteropelvic junction

obstruction. Typical coronal and axial image
Renal Cyst
Polycstic Kidney Disease

MRI of Urogenital Tract
• Alternative or complementary imaging modality

to intravenous urography, ultrasonography and
computed tomography.
• Primarily used as an additional tool of renal
imaging .
Normal Appearances
Coronal T2 HASTE (A) and axial T1 radient echo
FLASH (B) images showing good
corticomedullary differentiation. The medulla
is bright on T2WI compared to cortex. The
renal sinus is also bright due to fat and urine.
The T1WI show lower signal of the medulla
and sinus shows bright fat. The pararenal fat is
bright on T1 and intermediate in signal on T2
images
MR Urography
MR urography, T1 FLASH coronal image
showing excellent outlining of the pelvicalyceal
system and the ureters by excretion of injected
gadolinium contrast
Nuclear Medicine in Urinary Tract Imaging
• Alternative or complementary imaging modality to intravenous

urography, ultrasonography and computed tomography.
• Primarily used as an additional tool of renal imaging .
• possible to assess split renal function in various renal and urinary
tract disorders, evaluate kidney size in advanced azotemia, detect
the presence of kidneys which are poorly functioning, evaluate
renal perfusion, obtain a differential diagnosis of the upper
urinary tract dilatation, diagnose urinary tract obstruction, detect
intrarenal space-occupying lesions and monitor the renal function
in renal failure.
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Pemeriksaan Penunjang Urologi

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Departemen Bedah RSMH/FK Unsri

Pendidikan Dokter Spesialis-1 Ilmu Bedah

Dr. Ferdi Stefiyan

BNO (Blass Nier Overzicht)

5 minute : fase renogram, 10 minute: pyelogram,

Retrograde Urethrography : Technique

Retrograde Urethrography : Indication

Retrograme urethrogram shows complete disruption of posterior urethra

A : bipolar urethrocystogram of posterior urethral disruption injury

Cystogram reveals extraperitoneal bladder rupture with extravasation

Normal Sonographic Appearance

Normal Sonographic Appearance

Normal Sonographic Appearance

Acute pyelonephritis Appearance

Ultrasound of acute pyelonephritis. Arrows show abnormally echogenic and

Acute renal abscess Appearance

Polycstic Kidney Disease

Normal Sonographic Appearance

Normal Sonographic Appearance

Normal Sonographic Appearance

• the kidney is a much better understood organ as

NORMAL RENAL STRUCTURE AND

Transverse CT images obtained with a

NORMAL RENAL STRUCTURE AND

Axial CT scan showing

(A) Noncontrast axial CT showing a large hypodense mass

Multiplanar Reformation (MPR)

Volume Rendered Technique (VRT)

Noncontrast axial CT (A) showing a radiodensity at the right ureterovesical

MDCT IN BLUNT RENAL TRAUMA

• MDCT involving fast volume scanning requires

Corticomedullary phase (A and B) of contrast enhanced CT depicting a large

Renal Pelvis Laceration

Computed tomography showing right medial extravasation of contrast material in

Noncontrast computed tomography of left ureteropelvic junction

Polycstic Kidney Disease

MRI of Urogenital Tract

• Alternative or complementary imaging modality

Nuclear Medicine in Urinary Tract Imaging

• Alternative or complementary imaging modality to intravenous

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