Outline. Introduction to imaging modalities of the urinary system. Case base learning of common diseases in urinary tract

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2 Outline Introduction to imaging modalities of the urinary system Case base learning of common diseases in urinary tract

3 Outline Introduction to imaging modalities of the urinary system Case base learning of common diseases in urinary tract

4 Diagnostic Investigations in Urinary System PLAIN KUB EXCRETORY UROGRAPHY RETROGRADE PYELOGRAPHY ULTRASOUND COMPUTED TOMOGRAPHY MAGNETIC RESONANCE IMAGING ANGIOGRAM

5 The general used investigations in urinary tract system PLAIN RADIOGRAPHY: PLAIN KUB EXCRETORY UROGRAPHY RETROGRADE PYELOGRAPHY ULTRASOUND COMPUTED TOMOGRAPHY (CT)

6 PLAIN RADIOGRAPHY Density levels 1. Air density 2. Fat density 3. Soft tissue/fluid/water density 4. Bone/calcific density 5. Metallic density

7 PLAIN KUB Renal shadows Psoas shadows Bladder shadow Calcification Bony structure Other soft tissue structures: liver/spleen, abnormal mass

8 STAGHORN STONE 8

9 VESICAL STONE 9

10 Excretory Urography Intravenous pyelography: IVP Intravenous urography: IVU Advantages -Anatomy: kidney and collecting system -Excretory function -Obstructive uropathy 10

11 Excretory Urography Scout image Dynamic study - 1-min film / 5-min of both kidneys min or other delayed images - full bladder image Post-void image 11

12 Normal Pyelogram (IVP 5 min) minor calyx major calyx renal papilla renal papilla renal pelvis ureter

13 NORMAL IVP 13

14 Excretory Urography 1. Anatomy: Renal size, shape, axis and position 2. Excretory function: normal, delay, poor, no excretion 3. Obstructive uropathy: hydronephrosis, hydroureter 4. Distortion or destruction of collecting system 5. Filling defect in pelvocalyceal system, ureter or bladder 14

15 A 55-year-old man with hematuria 15

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18 Retrograde Pyelography (RP) Direct injection of contrast medium into pelvicalyceal system or ureters via the catheter Demonstrates pelvicalyceal system and ureters Limitations - invasive technique: cystoscope - cannot evaluate renal function 18

19 Retrograde Pyelography Indications Evaluate collecting system in patients with hematuria Findings on IVP, US, or CT are not clear Poor renal excretion Contraindication Urinary tract infection 19

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21 ULTRASOUND (US) Safe and cheap Portable No radiation No intravenous contrast medium Advantages for patients with renal failure, children and pregnancy Limitation to evaluate renal function or obese patient

22 KIDNEY Normal sonographic finding Shape: bean shape Size: 9-12 cm. in long axis Echogenicity: - Renal parenchyma: hypoecho and 1 cm in thickness - Central part or renal sinus: hyperecho

24 HYDRONEPHROSIS

25 CHRONIC RENAL DISEASE 25

26 NORMAL BLADDER 26

27 Color-Doppler Ultrasound Evaluate renal vascular disease - Renal artery - Renal vein Evaluate tumor vascularization

28 Color-Doppler Ultrasound 28

29 COMPUTED TOMOGRAPHY (CT) Indications Detection and characterization of adrenal gland, KUB system and pelvic organ Evaluate retroperitoneal disease Staging tumor and follow up after treatment Limitations Pregnancy: radiation Renal insufficiency/failure : CT need IV contrast medium administration

30 Renal cell carcinoma

31 CT Urography (CTU)

32 CT ANGIOGRAPHY (CTA)

33 Outline Introduction to urinary tract Case base learning of common disease in urinary tract

34 Hematuria Causes of hematuria Stone Tumor Infection

35 Case 1 : A 46-year-old woman with right colicky pain and hematuria

36 Urinary calculi Opaque stones : calcium oxalate, carbonate, phosphate Poor density stones : uric acid, xanthine, cystine

37 Urinary calculi Plain KUB / IVP Location: calyx, renal pelvis, ureter, bladder Shape: staghorn, round/oval (ureteric stone), lamellation (vesical stone) IVP Severity and location of obstruction Renal function

38 Semiopaque vesical stones

39 Differential diagnosis Filling defects in collecting system blood clot tumor stone fungal ball polyp air bubble

40 Ultrasound Urinary calculi Diagnosis of non-opaque stone echogenic material with acoustic shadow Severity and location of obstruction Renal size and cortical thickness

41 Renal stone with hydronephrosis Vesical stone

42 Urinary calculi CT scan Lt.renal stone Lt.renal stone

43 Quiz : Renal or extrarenal calcification?

44 Quiz : Renal or extrarenal calcification?

45 Quiz : Renal or extrarenal calcification?

46 Extra-urinary calcific shadows 1. Calcified costal cartilage 2. Calcified mesenteric LN 3. Calcified iliac and splenic vessels 4. Phleboliths 5. Gallstones, CBD, and cystic duct stones 6. Transverse process of L-spine 7. Intestinal content 8. Calcified appendicolith 9. Pancreatic calcification

47 Case 2 : A 50-year-old woman with underlying DM presented with fever and sepsis

48 Case 2 : A 50-year-old woman with underlying DM and present with fever and sepsis

49 Emphysematous pyelonephritis Rare, life-threatening condition Severe pyelonephritis with gas-producing organism (Gram-neg. bacilli: E.coli) Elderly diabetic patient (DM %) Clinical symptoms & signs : chills, fever, flank pain, lethargy, confusion, septicemic shock

50 Emphysematous pyelonephritis IVP Gas bubbles in renal bed, upper renal collecting system Renal enlargement Delayed or absent renal excretion Obliteration of the renal pelvis CT Investigation of choice Intraparenchymal, intracalyceal, intrapelvic gas and extension into perinephric space

51 Case 3: Spot diagnosis?

52 Renal Tuberculosis: Typical Findings Early : difficult to detect due to miliary tubercles in renal parenchyma Moderate : minimal irregularity of pyramid, fornix or isthmus : destruction of papilla : isthmus stenosis due to fibrosis : deformity of pelvicalyceal system : cavity (caseous material & necrosis) : reduction in renal size Severe : nephrocalcinosis (putty calcification) : autonephrectomy

53 Case 4: Spot diagnosis?

54 HORSESHOE KIDNEY Most common renal anomaly (1:400 live birth) Male : female = 2:1 Midline connection may be by functioning renal perenchyma or fibrotic band

55 Case 5: Diagnosis?

56 Case 5: Diagnosis?

57 SIMPLE CYST The most common renal masses ~ % of cases Occur in patients > 50 years old Solitary or multiple Bilateral cysts: less common Size: variable No symptom, incidental finding Serous containing

58 SIMPLE CYST US well defined, smooth wall anechoic posterior enhancement CT homogeneous water density thin septation may be identified no enhancement

59 Case 6: A 60-year-old man with hematuria

61 Renal cell carcinoma (RCC) Most common primary malignant renal tumor in adults Male : female = 2.5:1 Age : years Increased incidence Tobacco Acquired cystic disease of uremia Hemodialysis

62 Renal cell carcinoma (RCC) Clinical presentation: Classic triad: gross hematuria (60%) flank pain (50%) palpable renal mass (<10%) Distant metastases: lung, bone, liver and brain

63 Renal cell carcinoma (RCC) IVP distortion, enlarged renal portion displaced / obliterated collecting system, filling defect diminished function soft tissue mass US : Hyperechoic mass with inhomogeneity CT : Hypervascular renal mass

64 Case 7: What is it?

65 Case 8: What is type of calcification?

66 Which cases did you learn today? 1.Calculous disease D/D calcification on plain KUB 2.Infection bacterial, TB 3.Renal cystic disease 4.Congenital anomaly - horseshoe kidney 5.Renal tumor 6.Calcified ovarian dermoid/uterine fibroid myoma

67 REFERENCES 1. Armstong P, Rockall A, Wastie M. Diagnostic imaging. 6th ed. Williston: Wiley Blackwell; Dunnick R, Sandler C, Newhouse J. Textbook of Uroradiology. 5th ed. Lippincott Williams & Wilkins;

Outline. Introduction to imaging modalities of the urinary system. Case base learning of common diseases in urinary tract

Outline. Introduction to imaging modalities of the urinary system. Case base learning of common diseases in urinary tract Outline Introduction to imaging modalities of the urinary system Case base learning of common diseases in urinary tract Diagnostic Investigations in Urinary System PLAIN KUB EXCRETORY UROGRAPHY RETROGRADE