Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract Modalities Plain films KUB Plain films plus contrast IVP or IVU RUG, cystogram, pyelogram Cross-sectional imaging CT, MRI, US angiography inferior venacavography

Imaging of the Genitourinary Tract normal study

UROGRAFI INTRAVENAPERSIAPANDiet lunak.Puasa 8 jam (dari malam hari; makan dan minum).Cek ureum dan creatinin (2,5).Laksansia.

DOSIS :Dewasa: 0,5-1cc/ kg bbAnak: 1-2cc/kg bb

INDIKASI:Kelainan kongenitalInfeksiBatuTraumaTumorHematuria (mikro, gros)YANG DINILAI PADA IVP ADALAH PERJALANAN KONTRAS

Interval for taking film :30 second 1 minute: nephrogram phase4 5 minute : visualization of the collecting system 8 15 minute: ureter25 40 minute: urinary bladder60 minute: if necessary2 hours: unvisualized kidneyDelayed urography : 1,3,6,12,24 hours until the point of obstruction demonstratedPost void film: ability to empty the bladder evaluate the distal ureter that may be hidden by opacified bladder on the prevoiding radiograph evaluate bladder mucosaTUJUAN PERMENIT: EKSKRESI KONTRAS PADA PUNCAKNYA

If the lower ureter are not actually visualized : prone position compressionContra indication compression :Ureter ObstructionAorta aneurismAcute abdomenOblique film : Superimposed of the urinary tractDefect of the urinary tractUPRIGHT : Ren MobilisMost inferior portion of bladder : cystocele / hernia

YANG DINILAIKontur, ukuran dan letak kedua ginjal.Pengisian PCS: Normal : menit ke5-15; > 15 mnt :delayed; >2 jam: NON /UNVISUALIZED KIDNEYPELEBARAN PCS KANAN/KIRIN: TAK MELEBAR KALIKS MINOR : CUPPINGMelebar : Blunting, Flattening, Rounding, BallooningURETER KANAN/KIRI: Normal: tak melebarIngat 3 tempat penyempitan ureter: PUJ, penyilangan dg a. iliaca, UVJ.

VU: dinding (N. reguler; tidak reguler: sistitis)Adakah indentasi, filling defect dan add shadow.POST MIKSI/ POST PENGOSONGAN KATETER:Residu urine: normal: minimal, jika banyak/cukup banyak: sistitis.Apabila dengan kateter maka fungsi pengosongan tidak perlu dinilai.Lihan bendungan: N: tidak tampak bendunganTotal: apabila tidak ada aliran kontras pada bagian distalnya, atau bendungan sama antara pre dan post miksiParsial: apabila ada aliran kontras di distalnya atau besarnya bendungan berkuarang dibanding pre miksi.

GRADING HIDRONEFROSIS IVP

Imaging of the Genitourinary Tract horseshoe kidney

Imaging of the Genitourinary Tract stone at UVJ with surrounding edema

Imaging of the Genitourinary Tract ureteral calculus

Imaging of the Genitourinary Tract renal cysts

Imaging of the Genitourinary Tract polypoid filling defect in renal pelvis: TCC

Imaging of the Genitourinary Tract TCC

Imaging of the Genitourinary Tract internal iliac artery aneurysm

Imaging of the Genitourinary Tract vaginal mass, uterine impression

RPG (RETROGRADE PYELOGARFI)Jika IVP gagal/ nonvisualized kidney maka dilakukan RPG. Tujuan: Untuk mengetahui letak obstruksiDengan dipasang kateter sampai PCS melalui sistostomi oleh dr. bedah).Lalu isikan kontras sambil tarik kateter pelan sampai VU terisi.

CYSTOGRAPHYPurpose :Show bladder rupturLow pressure vesicoureteral refluxVesical fistulaMethod :Using folley catheter, contrast media instilled into urinary bladder until the limit of the patient comfort.Take the radiograph : AP, oblique, post evacuation.lateral ( if necessary ).Oblique : to distinguish filling defect / diverticula. Post evacuation : vesical diverticula, filling defect caused by neoplasm, vesicoureteral reflux.

Imaging of the Genitourinary Tract prostatic enlargement, bladder outlet obstruction

Imaging of the Genitourinary Tract bladder diverticula, neurogenic bladder

Retrograde Cystouretrography :Purpose : describing vesica urinaria, vesical neck, urethra anterior & posterior.

Method : Using 12 14 catheter Folley inserted into urethra until deflated baloon just appear inside the meatus.(fossa naviculare)Dynamic study : contrast injected under fluoroscopic control.

CYSTOURETHROGRAPHY

Bipoler Cystourethrography :Purpose :describing vesica urinaria, vesical neck, urethra anterior & posterior.Method :Using folley catheter, contrast media instilled into urinary bladder until the limit of the patient comfort.Take the radiograph : AP, oblique ( if necessary )Using 12 14 catheter Folley inserted into urethra until deflated baloon just appear inside the meatus.(fossa naviculare)Dynamic study : contrast injected under fluoroscopic control.

Micturition / Voiding Cystourethrography :Purpose : Demonstrate the external urethral sphincteric mechanism.Evaluate the urethraDiagnose high pressure vesicoureteral refluxMethod :The bladder should be filled until the patient is certain she / he can void after the catheter removed.Male : 450 oblique position, so entire urethra can be demonstrated, Female : APCan be used double-bubble catheter : OUI & OUE

VESICO URETERAL REFLUX (VUR)

INTERNATIONAL CLASSIFICATION OF VESICOURETERAL REFLUXGRADE I: Reflux only into ureterGRADE II: Reflux into collecting system, without dilationGRADE III: Reflux into collecting system with mild dilationGRADE IV: Reflux into collecting system, with moderate dilationGRADE V: Reflux into collecting system, with severe dilation

NORMAL URETHRA

Imaging of the Genitourinary Tract CT Imaging can identify hydronephrosis due to ureteric orifice involvement abnormal lymphadenopathy pelvic organ and side wall invasion distant mets Pitfall Unreliable in delineating primary tumor at bladder neck or dome

Imaging of the Genitourinary Tract Stage I

Imaging of the Genitourinary Tract Solitary Renal Mass DDx: cyst, AML, RCC, abscess? lymphoma

Imaging of the Genitourinary Tract Renal Lymphoma

Imaging of the Genitourinary Tract Renal Lymphoma

Imaging of the Genitourinary Tract Stage II extension into perinephric fat thickening of renal fascia adrenal gland involvement visible collateral vessels

Imaging of the Genitourinary Tract Stage IIIA RV invasion and extension into IVC

Imaging of the Genitourinary Tract Tumor Thrombus in Renal Vein, IVC

Imaging of the Genitourinary Tract Tumor Thrombus in Renal Vein and IVC

Imaging of the Genitourinary Tract Stage IIIB regional lymph node metastases if > 2cm, almost always contain tumor clusters more suspicious CT: > 80% sens. & spec. Pitfall inflammatory nodes

Imaging of the Genitourinary Tract Stage IIIB

Imaging of the Genitourinary Tract Stage IV invasion of adjacent organs difficult to determine by CT

Imaging of the Genitourinary Tract Stage IV distant mets lungs (37%) bones & liver (33%) mesentery, adrenals abdominal wall, brain, pancreas

Imaging of the Genitourinary Tract Stage IV

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract Testicular Carcinoma most common malignancy in males aged 15 to 35 germ cell tumors 95% of testicular tumors Seminomatous Non-seminomatous non-germ cell tumors Sertoli, Leydig cells Lymphoma Leukemia Metastases Seminoma

Imaging of the Genitourinary Tract Seminoma

Imaging of the Genitourinary Tract Metastatic Choriocarcinomararely exists in pure form peak incidence in 2nd and 3rd decade highly malignant tumor, metastasizes early

Imaging of the Genitourinary Tract Mature teratoma in a 22-year-old manSubtypes: mature, immature, malignant benign in children, malignant in adults

Imaging of the Genitourinary Tract Hydrocele fluid collection between layers of tunica vaginalis congenital patent processus vaginalis communication between abdomen and scrotum acquired inflammation, torsion, trauma, idiopathic, neoplasm, surgery

Imaging of the Genitourinary Tract Varicocele dilated, tortuous pampiniform plexus, > 2 mm common cause of male infertility (Rx: embolization) primary absent or incompetent valves collateral bypass secondary pressure on spermatic vein hydronephrosis, masses accentuated by upright position, valsalva

Imaging of the Genitourinary Tract Scrotal Hernia Hernia Contents: omental fat, small bowel, large bowel

Imaging of the Genitourinary Tract DDx of Acute Scrotum Testicular Ischemia torsion post surgical, trauma, infarction Scrotal Inflammation epididymitis epididymo-orchitis Scrotal Trauma Neoplasm rare cause of acute scrotum

Imaging of the Genitourinary Tract Testicular Torsion Sonography diffusely hypoechoic hydrocele absence of intra-testicular flow Nuclear Scintigraphy very high sensitivity, specificity ? availability Problem Situations intermittent torsion torsion of appendix testis

Imaging of the Genitourinary Tract Epididymo-Orchitis skin thickening, complex hydrocele, hypoechoic testis, marked hypervascularity

Imaging of the Genitourinary Tract Testicular Rupture rapid, non-invasive, highly sensitive confirmation of clinical suspicion imaging findings focal alteration in testicular echogenicity discrete fracture plane hematocele vascular disruption on Color Doppler Sonography

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract

Imaging of the Genitourinary Tract