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 PYELOGRAPHY ULTRASOUND COMPUTED TOMOGRAPHY MAGNETIC RESONANCE IMAGING ANGIOGRAM

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

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

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

STAGHORN STONE 8

VESICAL STONE 9

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

Excretory Urography Scout image Dynamic study - 1-min film / 5-min of both kidneys - 10- min or other delayed images - full bladder image Post-void image 11

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

NORMAL IVP 13

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

A 55-year-old man with hematuria 15

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

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

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

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

HYDRONEPHROSIS

CHRONIC RENAL DISEASE 25

NORMAL BLADDER 26

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

Color-Doppler Ultrasound 28

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

Renal cell carcinoma

CT Urography (CTU)

CT ANGIOGRAPHY (CTA)

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

Hematuria Causes of hematuria Stone Tumor Infection

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

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

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

Semiopaque vesical stones

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

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

Renal stone with hydronephrosis Vesical stone

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

Quiz : Renal or extrarenal calcification?

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

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

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

Emphysematous pyelonephritis Rare, life-threatening condition Severe pyelonephritis with gas-producing organism (Gram-neg. bacilli: E.coli) Elderly diabetic patient (DM 87 89 %) Clinical symptoms & signs : chills, fever, flank pain, lethargy, confusion, septicemic shock

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

Case 3: Spot diagnosis?

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

Case 4: Spot diagnosis?

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

Case 5: Diagnosis?

SIMPLE CYST The most common renal masses ~ 65-70 % of cases Occur in patients > 50 years old Solitary or multiple Bilateral cysts: less common Size: variable No symptom, incidental finding Serous containing

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

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

Renal cell carcinoma (RCC) Most common primary malignant renal tumor in adults Male : female = 2.5:1 Age : 50-70 years Increased incidence Tobacco Acquired cystic disease of uremia Hemodialysis

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

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

Case 7: What is it?

Case 8: What is type of calcification?

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

REFERENCES 1. Armstong P, Rockall A, Wastie M. Diagnostic imaging. 6th ed. Williston: Wiley Blackwell; 2009 2. Dunnick R, Sandler C, Newhouse J. Textbook of Uroradiology. 5th ed. Lippincott Williams & Wilkins; 2013 67