THE URINARY TRACT

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THE URINARY TRACT Methods of examination Plain
film of the abdomen patient in supine position,
kidneys, ureteral and bladder areas. Assessment
of the size, shape and position of the kidneys,
the presence of calcium, psoas muscle
abnormalities. IVU i.v. injection of
radioopaque contrast medium. Serial films are
obtained over 25 minutes as the contrast agent
is excreted by the kidneys for visualization of
the renal collecting system, ureters and bladder
(first film obtained after 1 minute and a second
film after 5 minutes). Compression film.
Patient preparation bowel cleansing to remove
gas and fecal matter from the colon.
Contraindications to injection of i.v. contrast
medium - hypersensitivity to the contrast
agent - renal and hepatic disease - asthma - a
serum creatinine level higher than 1,5 1,8
mg/100ml - multiple myeloma - history of severe
allergy
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US CT MRI Retrograde pyelography cystoscopy
and catheterization of the ureters are
necessary. Antegrade pyelography a needle is
placed percutaneously into the renal pelvis from
a posterolateral approach and either fluoroscopic
or ultrasonic guidance is used. Conventional
percutaneous nephrostomy, brush biopsy, stent
placement, stone dissolution or extraction,
dilation of stenosis can be performed Renal
angiography first global aortography followed
by selective renal artery catheterization. Used
for renal angioplasty/stenting and renal
embolization. Cystography a urethral catheter
is inserted and the bladder is filled with
contrast medium. Indications bladder rupture,
tumors, diverticula. Renal scintigraphy 99Tc.
Indication renal function.
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Anomalies in number Renal agenesis single
kidney. Method of choice angiography. Supern
umerary kidney the anomalous kidney is small
- the other kidney on the same side is often
smaller than the normal kidney on the opposite
side. - demonstration of the presence of a
separate pelvis, ureter and blood supply is
necessary for the diagnosis.
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• Anomalies in size and form
• Hypoplasia
• usually associated with hyperplasia on the
  other side.
• The hypoplastic kidney functions normally.
• the collecting system is small
• there is a normal relation between the amount of
  parenchyma and the size of calices and renal
  pelvis.
• Differentiai diagnosis - acquired atrophic
  kidney small kidney because of vascular or
  inflammatory disease.

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• Anomalies in size and form
• Hyperplasia is associated with agenesis or
  hypoplasia
• on the opposite side
• - more properly termed compensatory hypertrophy.
  
• Conditions that usually cause bilateral renal
  enlargement
• acute glomerulonephritis,
• lymphoma, leukemia in children,
• systemic lupus erithematosus,
• polycystic disease,
• bilateral renal vein thrombosis,
• amyloidosis,
• sarcoidosis,
• lobular glomerulonephritis,
• total lipodystrophy.

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• Fusion anomalies
• Horseshoe kidney the lower poles of the kidney
  are joined by a band of soft tissue, the isthmus.
  
• the long axis of the kidney is reversed ? the
  lower pole is nearer the midline than the upper.
• associated rotation anomaly ? the calyces are
  directed backward or posteromedially.
• the ureters tend to be streched over the isthmus
  ? partial obstruction is not unusual ? dilation
  of the pelvis and calyces.
• Crossed ectopy fusion of the kidneys on the
  same side
• - the lower kidney is ectopic and its ureter
  crosses the midline to enter the bladder normally
  on the opposite side.

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Anomalies in position Ectopy pelvis,
thorax Nephroptosis downward displacement and
more mobility of the kidney than
usual. Malrotation results from incomplete or
excessive rotation and urographic study
indicates the degree of anomaly.
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PA
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Anomalies of the renal pelvis and
ureter Ureteropelvic junction anomalies
bilateral but not always simmetrical.
Duplication of the pelvis and ureter Retrocaval
ureter is limited to the right side. - The
ureter passes to the left behind the
IVC. Ureterocele intravesical dilation of the
ureter immediately proximal to its orifice in the
bladder. - resembles a cobra head in shape. -
When the ureterocele is not filled with contrast
- radiolucent mass within the opacified bladder
in the region of the ureteral orifice. - If it
is filled, the lesion is outlined by a
radiolucent wall that stands out in contrast to
the filled bladder and to the filled, dilated,
distal ureter. Ureteral diverticula
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OBSTRUCTIVE UROPATHY Nonobstructive
hydronephrosis diabetes, - infections,
- appendicitis, peritonitis Congenital
hydronephrosis obstruction at the UPJ, -
vesicoureteral reflux, - congenital
ureterocele, - urethral valves, congenital
strictures. Acquired hydronephrosis tumors,
- calculi, - strictures, - radiation
therapy, - surgery, - prostatic enlargement,
- pregnancy in the third trimester.
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• OBSTRUCTIVE UROPATHY
• Imaging findings
• US method of first choice to evaluate patients
  with suspected hydronephrosis (mild, moderate,
  severe).
• CT i.v.contrast medium useful to assess the
  cause of obstruction.
• Urography
• early flattening of the normal concavity of
  the calyx decrease in the rate of contrast
  material accumulating in the collecting system.
• Calyces then gradually enlarge with progressive
  destruction of parenchyma.
• A prolonged and increasingly dense nephrogram is
  characteristic of acute renal obstruction.
• In severe cases do percutaneous nephrostomy.

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CALCULI Incidence 5 of population 20 at
autopsy. Recurrence of stone disease
50. Predisposing conditions calyceal
diverticuli, renal tubular acidosis,
hypercalcemia, hypercalciuria. The radiographic
density of a calculus depends on its calcium
contents - Calcium calculi (opaque) 75 -
calcium oxalate and phosphate. - Struvite calculi
(opaque) 15 - magnesium ammonium
phosphateinfection stones - Cystine calculi
(less opaque) cystinuria. - Nonopaque calculi
uric acid, xanthine, mucoprotein matrix calculi
in poorly functioning, infected urinary tract.
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Radiographic features Calculus - determine size,
number, location Radioopaque calculus are best
detected on KUB or helical CT Radiolucent calculi
are best detected by IVU US renal calculi -
hyperechoic focus, posterior shadowing IVU -
Delayed and persistent nephrogram ? ureteral
obstruction - Ureter distal to calculus is
narrowed (edema, inflammation), may create false
impression of stricture - Ureter proximal to
calculus is persistently minimally dilated CT -
detects most calculi regardless of calcium
content - Helical CT is very useful to detect
small calculi
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• Location 3 narrow sites
• UPJ, at crossing of ureter with iliac vessels,
  UVJ
• Complications
• - Forniceal rupture (pyelosinus backflow)
• - Chronic calculous pyelonephritis
• - XGP
• Treatment options
• Small renal calculi (? 2,5cm) ESWL
• (extracorporeal shock wave lithotripsy)
• - Large renal calculi (? 2,5 cm) percutaneous
  removal
• Upper ureteral calculi ESWL
• Lower ureteral calculi ureteroscopy
• Differential diagnosis
• - Gallstones
• - Calcification of costal cartilage
• - Calcified mesenteric nodes
• - Calcifications in cysts and tumors
• - Vascular calcification

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Staghorn calculus
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URINARY TRACT INFECTION Acute pyelonephritis Acute
bacterial infection of the kidney and urinary
tract Proteus, Klebsiella, E.Coli Types -
focal type lobar nephronia -
diffuse type more severe and extensive Role of
imaging studies - Define underlying pathology
obstruction, reflux, calculus - Rule out
complications abscess, emphisematous
pyelonephritis Radiographic features US - renal
enlargement (edema) - loss of
corticomedullary differentiation (edema) - IVU
delay of contrast excretion, narrowing of
collecting system, striated nephrogram, - CT -
areas of decreased perfusion by
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• Chronic pyelonephritis
• Criteria for diagnosis
• - Scarring - can affect the entire thickness of
  renal substance ? the involved papilla is
  retracted ? secondary dilation of its calyx
• the involved area? irregular surface depression
• The dilated calyx - smooth margin, variable
  shape
• Renal tissue adjacent to the involved area is
  normal or hypertrophied
• unifocal or multifocal, one or both kidneys
• decreased size of the involved kidney

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RENAL ABSCESS Usually caused by gram negative
bacteria. Underlying disease calculi,
obstruction, diabetes, AIDS.   Radiographic
features Well-delineated focal renal
lesion Central necrosis Thickened abscess wall
with contrast enhancement Perinephric
inflammatory involvement Complications
retroperitoneal spread of abscess,
renocolic fistula
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TUBERCULOSIS GU tract is the second most common
site of TB involvement after the lung. The
disease is typically due to hematogeneous
spread. Clinical history of pulmonary TB,
pyuria, hematuria, dysuria Radiographic
features Distribution unilateral involvement is
more common 70 Size early - kidneys are
enlarged - late - the kidneys are small,
autonephrectomy Parenchyma - calcifications
curvilinear, mottled, amorphous -
Papillary necrosis, parenchymal cavity
- Tuberculoma - Parenchymal
scarring Collecting system - infundibular
stenosis - amputated calyx - Corkscrew ureter
multiple stenosis - pipestem ureter - narrow,
rigid, aperistaltic segment
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CYSTIC DISEASE Symple cysts Probably arise from
obstructed tubules or ducts. They do not
communicate with the collecting system. Clinical
most commonly asymptomatic rare
hematuria   Radiographic features IVU lucent
defect, cortical bulge, round indentation on the
collecting system US anechoic, sharply
marginated, smooth walls, very thin septation may
be seen CT homogeneous water density, no
enhancement. - smooth cyst wall, sharp
demarcation from the surrounding renal parenchyma
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Complicated cysts Bosniak classification -
category 1 lesions benign simple cyst -
category 2 lesions these minimally complicated
cysts are benign but have certain radiologic
findings of concern.This category includes
septated cysts, minimally calcified cysts,
high-density cysts - category 3 lesions
complicated cystic lesions that exibit some
radiologic patterns also seen in malignancy. This
category includes complex septated cyst, heavily
calcified cyst. Surgery is usually performed -
category 4 lesions clearly malignant lesions
with large cystic component. Irregular margins,
solid vascular elements
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• ADULT POLYCYSTIC KIDNEY DISEASE
• Cystic dilation of collecting tubules as well as
  nephrons. Autosomal dominant trait.
• Clinical slowly progressive renal failure.
• Treatment dialysis, transplant.
• Associated findings hepatic cysts, intracranial
  aneurysm, cysts in pancreas and spleen.
• Radiographic features
• kidneys are enlarged and contain innumerable
  cysts, creating a boselated surface.
• They do not communicate with the collecting
  system
• - calcification of cyst wall is common
• - pressure deformities of calyces and infundibula
• - swiss-cheese nephrogram

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BENIGN TUMORS Angiomyolipoma Hamartomas
containing fat, smooth muscle and blood
vessels. Treatment small lesions are not
treated large and symptomatic lesions are
resected or embolized Complication tumors may
spontaneously bleed because of their vascular
elements CT method of choice Adenoma Low grade
adenocarcinoma with no metastatic potential.
Usually detected at autopsy Oncocitoma These
tumors arise from oncocytes of the proximal
tubule. Radiographic features central stellate
scar (CT) , well-defined sharp borders Juxtaglomer
ular tumor (reninoma) Secretion of renin causes
HTN, hypernatremia, hypokalemia. Tumors appear as
small hypovascular masses
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RENAL CELL CARCINOMA Synonyms renal
adenocarcinoma, hypernephroma, clear cell
carcinoma Clinical hematuria, flank pain,
palpable mass, weight loss, paraneoplastic
syndrome hypertension (renin), erythrocytosis
(erythropoietin), hypercalcemia (PTH),
gynecomastia (gonadotropin), Cushing syndrome
(ACTH) Risk factors tobacco, phenacetin long
term use, Von Hippel-Lindau disease, chronic
dialysis, family history
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Radiographic features IVU renal mass with renal
contour deformity, - calyceal
displacement and destruction US hypoechoic,
nonhomogeneous, irregular borders CT hypodense
mass, enhancement - calcifications,
necrosis, irregular borders Angiography
hypervascular, caliber irregularities of tumor
vessels, - prominent AV shunting, venous lakes,
- preoperative embolization Staging Stage I
tumor confined to kidney Stage II extrarenal
but confined to Gerotas fascia Stage III A
venous invasion B- lymph node metastases C
both Stage IV A direct extension into adjacent
organs IV B metastases (lung,
liver, bone, adrenal, contralateral
kidney) Therapy radical nephrectomy,
chemotherapy, radiotherapy
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Renal pelvis tumors transitional cell
carcinoma Tumors are often multifocal ureter,
bladder. Radiographic features - irregular
filling defect - polypoid mass. - wall
thickening infiltrative cancer
Staging Stage I mucosal lamina propria
involved Stage II into but not beyond muscular
layer Stage III invasion of adjacent fat /
renal parenchyma Stage IV - metastases
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URINARY BLADDER
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