gu radiography sem5

7/23/2019 GU Radiography SEM5

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Imaging of the Genitourinary TractBlok 17

Keluhan dan penyakit berkaitan dengansistem uropoetik

Semester V

Mashuri, dr.,Sp.Rad.,M.Kes

Department of RadiologyFaculty of Medicine

University of Lambung

Mangurat!

Ulin "ospital


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%maging Modalities

&onventional non contrast 'lain ()Ray

&onventional *ith contrast %ntravenous pyelography +ntegrade pyelography Retrograde 'yelography Retrgograde &ystography Retrograde Urethrography

&ystourethrography #ipolar cystourethrography oiding &ystourethrography Retrograde cystourehtrography


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-on)conventional Ultrasound &omputed omography Scan

Digital Substraction +ngiography /DS+0 -uclear Medicine /Scintigraphy0 Magnetic Resonance %maging /MR%0


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Position of kidneys:

R: L1-L3

L: T12-L3

Kidneys


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Long axis of the kidneys is directed downward and outward, parallel to the

lateral border of the psoas uscles


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Ureter


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Urinary #ladder


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Urethra


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'lain 'hoto +bdomen /KU#0

or #-1 %ndication2 Renal opa3ue calculi, 'reparation for %U

&hec placement ofcatheters!stents!drains!foreign bodies

&ontraindication2 none

echni3ue2 supine position


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'lain photo abdomen

KU#

All exposures at endof expiration for anyurinary system study

he Last 4 Ribs +ll Lumber +nd Sacral

ertebrae 'soas Muscles Symphysis 'ubis


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Plain X-ray film

Renal shadow !astrointestinal tract shadow "alcification or radiopa#ue shadow

$soas shadow %one


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%U /dulu %'0

5. Suspected congenital anomaly

4. Renal umor

6. Renal colic

7. 'ersistent urinary tract infection8. Renal rauma

%ndications


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'reparation

+fter midnight2 -il 'er 1s /9puasa: ; < hours0

#o*el cleansing

&lear li3uid diet

Don=t tal to much and smoing

>mpty bladder

Free from contrast agenthypersensitivity


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Complications

1 . Immediate Minor: ausea! "omiting! arm pain! and headach Sever allergic:#rythema! urticaria! facial or glottic

edema.

Treatment$ antihistamines! steroids and%or epinephrine.

Chemotoxic or idiosyncratic reactions$ &most serious'Include$ con"ulsions! pulmonary edema! cardio"ascular

collapse! thrombosis! cardiac arrest. 1 of e"ery 7!()) The mortality rate for contrast administration! 1$1))!)))

*. +elayedephroto,icity$ -atients ith diabetic nephropathy!

creatinine le"els are /0 mg%dl. This nephroto,icity isusually re"ersible.

Complications

1 . Immediate Minor: ausea! "omiting! arm pain! and headach Sever allergic:#rythema! urticaria! facial or glottic

edema.

Treatment$ antihistamines! steroids and%or epinephrine.

Chemotoxic or idiosyncratic reactions$ &most serious'Include$ con"ulsions! pulmonary edema! cardio"ascular

collapse! thrombosis! cardiac arrest. 1 of e"ery 7!()) The mortality rate for contrast administration! 1$1))!)))

*. +elayedephroto,icity$ -atients ith diabetic nephropathy!creatinine le"els are /0 mg%dl. This nephroto,icity isusually re"ersible.

&ontrast +gent and +dverse Reactions

Crucial not to leave pt alone for first5 minutes after injection!

Crucial not to leave pt alone for first5 minutes after injection!


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%U procedure

5. 'reliminary /'lain photo04. %mmediate6. 8 minute

7. +bdominal compression8. Release?. 'ost micturation

Should ideally be tailored to answer theclinical question


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'reliminary Film /Foto %0

'recontrast KU#radiograph. o demonstrate

opacities that may lie

*ithin the urinary tract. o chec abdominal

preparation, positioningand e@posure factor.

+dditional radiograph)e@piration or obli3ue ofthe renal areas todetermine the positionof any opacities lie

*ithin the urinary tract.

(All exposures at end

of expiration for any

urinary system study)


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%mmediate film /Foto %%0

5)6 min post contrast radiograph

collimated to the idneys. o demonstrate the nephrogram phase.

he renal parenchyma opacified by the

contrast in the renal tubules.


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8 minute film /Foto %%%0

8 min post contrast KU# radiograph. o determine if e@cretion is symmetrical or

a further dose of contrast is re3uired if the

opacification is poor.

+bdominal compression is then applied if

no contraindication.


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+bdominal compression

&ontraindications2 >vidence of obstruction on 8 minute image

+bdominal mass

+bdominal aortic aneurysm

Recent abdominal surgery

Severe abdominal pain

Suspected urinary tract trauma


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&ompression Film /Foto %0

+ 58 min post contrast

collimated to the idneys.

o demonstrate

distended collecting

systems and pro@imalureters.

) effectively produces

partial ureteric

obstruction) %mproved calyceal detail

and more reliable ureteric

opacification upon release

of compression.


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Release film /Foto )%%0

+ 6A min post contrast KU# radiograph

follo*ing release of compression.

o demonstrate the entire urinary tract

particularly the lo*er ureters.

+dditional radiograph ) prone or upright

KU# *hen the lo*er ureters are not seen

ade3uately.


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'ost Micturation Film /Foto %%%0

'ost micturation KU# radiograph.

o demonstrate complete bladder

empting and any hold)up of contrast in

the collecting system.

'ersistence dilatation on post void image

suggest obstruction and decompression

indicates physiologic distension.


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>valuation of %U 'reliminary radiograph

Bas, mass, stones, bones

Renal shado*s) siCe, a@is,calcification

&ourse of ureter

%mmediate film/nephrogram0 SiCe, shape, symmetry,

contour

'yelogram &alices, ureters, urinary

bladder


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'yelography

+ntegrade pyelography /+'B0

1utline the pelvicalyceal system and

ureteric anatomy

&ontrast is in$ected into the '& system

and outline the '& and ureter

Retrograde pyelography /R'B0

Re3uires cystoscopy, placement of the

catheter to the distal part of ureter


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+ntegrade pyelography /+'B0

%ndications2 +natomic evaluation of pelvocalyceal

system

Ureteric drainage for evaluate

urine lea,

post)percutanea nephrostomy

residual stones

site of ureteric obstruction

ureteral fistulas

echni3ue2 Under flouroscopy

ia catheter nephrostomy *ith using

contras media

Supine position


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Retrograde Urography

%ndications2 "ematuria, &ontrast sensitivity, Suboptimal %U, -eeds cystoscopy

echni3ue2 Under fluoroscopy &ontrast in$ected

directly intopelvicaliceal systemvia cathethers fromurethrae

Supine positions


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&ystography


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&ystography

%ndications2 esicoureteral reflu@/bac*ard flo* of urine intoureters0

Recurrent lo*er urinarytract infection

-eurogenic bladder2/dysfunction due to diseaseof central nervous system orperipheral nerves0#laddertrauma

'rostate enlargement Lo*er urinary tract fistulae Urethral stricture 'osterior urethral valves

/obstructive congenital defect ofthe male urethra0


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&ystography techni3ue

echni3ue2 &ontrast administration usually performed

retrograde via catheter urethra,

&atheter cystostomy %U /e@cretory cystography0

&ystography Routine Series Scout vie*

filled +' both obli3ues Lateral oiding

post)void


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>@cretory&ystogram /%U0 Retrograde"ystogra


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Urethrography

&ndications: o diagnose urethral stricture o evaluate urethra after trauma

Techni#ue: Urethra may be visualised as part of M&U/descending0 or ascending urethrogram

+scending urethrogramtip of catheter is inthe fossa of navicular.

Spot film is taen *hen contrast is in$ected


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&ystourethrography

Static &ystourethrography

9Retrograde

&ystourethrography:9&ystourethrography:

#ipolar &ystourethrography

oiding &ystourethrogram /&UB0


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&ystourethrography

%ndications2 >valuate bladder lesion, rupture, lea, post

trauma!surgery bladder

integrity!anastomose!fistulas

echni3ue2 Scout,

Fill bladder *ith 4AA)7AA mL via urethrae syringe

or tip of catheter is in the fossa of navicular. +!' and obli3ues /sho*s e@travasation posterior

to bladder0,

'ost)drainage film


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&ystourethrography

echni3ue2

+' 1bli3ue 'ro$ection )

R'1!L'1

'atient is supine, rotated 68

) 7A degrees

Urethral syringe /or #rodney

clampE0 is used to introduce

contrast images are obtained

as contrast is in$ected

>ntire urethra must be

visualiCed

#ladder can be filled to

obtain antegrade voiding

study

Techni#ue: +' 'ro$ection /maybe obli3ues0

#ladder can be filled and patient

void for antegrade studies

&assette should be centered as

for cystography

+bduct thighs to prevent

superimposition of bone or soft

tissue

Male Female


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&ystourethrography

h &


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Micturating cystourethrogram/M&U0!


'unctional and anatoic e(aluation of bladder

&ndication:

1) To detect (esicoureteric reflux who ha(e recurrent

infection

2) %ladder rupture

3) *eonstrate posterior urethral (al(e

+) reterocele,

) *ysfunctional (oiding.) rethral strictures

/) %ladder0urethral di(erticula



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Scout 'ediatric2 8 or < F feeding tube, fill bladder *ith contrast

/age ;4 @ 6A0. Mainly for peadiatric patient

+dult2 standard catheter

Filling the bladder with contrast introduced via urethralcatheter

Film during filling) bladder pathology, early reflu@

Films during void) reflu@, urethral abnormality

1bli3ue) evaluate grade 5 reflu@, males

'ost)void film


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M&U


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(oidingcystourethrogra"!4 of a patient withgrade &&& (esicoureteral

reflux R4) 5ote thatthe contrast flows up theureter and into the renalpel(is) The calyces aresharp


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This is an exaple of

grade

(esicoureteral reflux

R4) 5ote thedilated renal pel(is

and calyces) The

ureter also is dilated

and tortuous)


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This is bilateral

(esicoureteral reflux

R4


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Ultrasound

&ndication

1) Renal ass

2) 6aeaturia

3) 'lank pain+) %lood urea ele(ation

) $oor non functioningkidney on &

.) %iopsy 0inter(entionalguidance

echni3ue

+ 6.8 transducer isgenerally used toscan the adult idney

Liver and spleen act asacoustic *indo* forevaluation R and Lidneys respectively

'atient position2Supine, decubitus orprone


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ltrasound of Right 7idney


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Ultrasound of Kidneys

NORMAL STUDY

DILATED RENAL

PELVIS


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The parenchya is

relati(ely noral in

thickness)

The dilation of thecollecting syste

extends fro the

renal pel(is to the

calyces)


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&omputed tomography

Biving predominantlyanatomicalinformation

Used *hen USfinding is inconclusive

Staging of tumor Renal trauma

Renal artery stenosis &alculi ! obstructive

uropathy

>mphysematous pyelonephritis


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>mphysematous pyelonephritis.


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&ystic renal cell carcinoma.

R&& *ith inferior vena cava


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R&& *ith inferior vena cava

invasion


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MR%

+natomical information

hen US or & is inconclusive

MR+2 for renal artery stenosis

Multiplanar imaging G sag, coronal and

a@ial

ime consuming ! e@pensive


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Large right renal cell carcinoma *ith renal vein

and inferior vena cava invasion.

T2-weighted axial

8R&


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*ynaic gadoliniu-enhanced agnetic

resonance angiogra 8R4 shows noralrenal arteries)

Renal +ngiography


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Renal +ngiography


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-uclear Scintigraphy

'hysiologic and anatomic info Renograph2

-on)imaging /Ulin "ospital0 ith imaging /Bamma camera0

Radioisotop;Radiofarmaa &)HH m /t I ? hrs0 M+B6) cleared by tubular secretion, no glomerular

infiltration) evaluate renal function and renal plasma

flo* D'+) glomerular filtration) evaluate obstruction

and renal function DMS+) cleared by filtration and secretion) renal

cortical image


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Urogenital Disease

+e"elopmental "ariations disorders

ollecting system &2bstruction! stone!hydronephrosis'

3cute and chronic inflammation

irculation disorders &reno"ascularhypertension! function failure'

&+iseases of the parenchyma' Trauma

Space occupying lesions%S24 &cystic! solid'

-ormal variations and


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-ormal variations and

congenital disorders

Fusion abnormalitiy "orseshoe odney

>@trarenal pyelon &ongenital malposition /ectopic idney0

+genesis, hypoplasia

1bstruction stone


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1bstruction, stone,

hydronephrosis +cute2

>nlarged idney

Slo* perfusion and e@cretion

Moderate dilatation of the pyelum, stone, othercauses

&hronic2

Dilated collecting system hin parenchyma

'ure e@cretion

Stone


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+utoimmun2 large!small idney

+cute pyelonephritis /acute focalbacterial nephritis, etc0

>mphysematous pyelonephritis2 large

idney, hypodensity, decreased contrast

uptae, space occupation, thiening of

the renal fascia, gas in the parenchyma

'yonephros 2 hydronephrosis, thi *all of

the pyelon

+bscess2 +'- ; abscess cavity

Segmental, polar, global atrophy


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Infarction &partial! complete'$ noenhancement! absence of e,cretion

5enal "ein thrombosis$ large kidney!

slo perfusion! "enous filling defect!perirenal collaterals! no e,cretion

5enal artery stenosis! reno"ascular

hypertension aneurysma Kidney failure$ parenchyma

destruction! calcification! pure

e,cretion &contrast material66'


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rauma

#lount or penetrating in$uries, contusion

"aematoma /subcapsular!perirenal0

Urinoma

'arenchyma laceration

+rtery!vein in$ury

Ureter ruptur


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S1L

&ystic Simple /soliter!multiple0

"erediter /poliisti disease0

+typical /closed caly@, diverticula, cystictumour, abscess, cystic nephroma0

Solid

#eigne /+ML, adenoma0 Malignant 'rimary /R&&, &&, ilms umor0

Secondary /"L, -"L, Metastasis0


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&ase 5. "orseshoe idney

xis and positionalteration in

horseshoe kidney)

& 4 filli d f i %U


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&ase 4. filling defect in %U

"oon causes

1) "alculi

2) "yst

3) Tuours+) %lood clot


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&ase 6. focal #ulge

Renal cyst withsplaying of calyces


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&ase 7. simple cyst

%ncreased parenchymal thicness Jdistortion of collecting system ) simple

cyst /confirm by us0

&ase ?. pcs


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&ase ?. pcs

duple@ 9xcretory urography in a

woan shows coplete

ureteral duplication on the

right) The upper oiety

ureter epties below andedial to the ureter of the

lower oiety)

5ote the duplex collecting

syste on the left

&ase . bilateral ureteral


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&ase . bilateral ureteral

duplication 9xcretory urography

in an adult patient

with bilateral

coplete ureteral

duplication)

& < d l i h id


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&ase


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&ase H.&alculus

&ntra(enous urogra) fter the intra(enous inection, contrast

aterial in the collecting syste obscures the calculus

& 5A U t


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&ase 5A. U stone

Standing column ofcontrast *ith mild

hydronephrosis ) U

stone.

&ase 55. "ydronephrosis J


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&ase 55. "ydronephrosis J

hydroureter ) ureterocele.

& 54 #'"


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&ase 54. #'"

#ladder base

defect )

prostate

enlargement


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"+-KS 1U

gu radiography sem5

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