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Author(s): J. Stuart Wolf, Jr., M.D., 2009 License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution–Share Alike 3.0 License: http://creativecommons.org/licenses/by-sa/3.0/ We have reviewed this material in accordance with U.S. Copyright Law and have tried to maximize your ability to use, share, and adapt it. The citation key on the following slide provides information about how you may share and adapt this material. Copyright holders of content included in this material should contact [email protected] with any questions, corrections, or clarification regarding the use of content. For more information about how to cite these materials visit http://open.umich.edu/education/about/terms-of-use. Any medical information in this material is intended to inform and educate and is not a tool for self-diagnosis or a replacement for medical evaluation, advice, diagnosis or treatment by a healthcare professional. Please speak to your physician if you have questions about your medical condition. Viewer discretion is advised: Some medical content is graphic and may not be suitable for all viewers.
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Kidney and Upper Urinary Tract
J. Stuart Wolf, Jr., M.D. Professor of Urology
Fall 2008
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Michigan Urology Center University of Michigan
Ann Arbor, MI
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Kidney and Upper Urinary Tract
Syllabus ! If I show you graphics that are NOT in
your syllabus ! Then they are NOT critical for the
test ! They are to familiarize you with
Urologic operative techniques, for their interest rather than for testing purposes
! Radiography will be on test, but not the actual images
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Kidney and Upper Urinary Tract
Objectives ! Appreciate importance, evaluation, and
differential diagnosis of hematuria ! Gain basic understanding of major
disease processes of kidney and upper tract ! Obstruction ! Calculi ! Infection ! Renal masses and cysts
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Kidney and Upper Urinary Tract
Hematuria
Clinically-Oriented Lecture
Evaluation and Differential
Case presentations of representative entities
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Hematuria
Hematuria ! Definition
! > 3 RBC / hpf in urinary sediment ! Dipstick is screening test only ! Dipstick is 95 % sensitive, but only
about ~ 80% specific ! In population with 10% hematuria, PPV
of Dipstick is only 35% ! Positive Dipstick indicates hematuria
ONLY when confirmed by microscopy of > 3 RBC / hpf
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Hematuria
Hematuria ! Additional Characterization
! Gross (grossly visible) or microscopic? – Gross more likely significant
! If gross, is it initial (urethra), terminal (bladder neck or prostate), or total (interior of bladder or upper tract)
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Hematuria
Evaluation 1: Examine Urine ! In women, get cath. UA if > 1 squamous
cell / hpf (vaginal contamination) ! Is color red but dipstick - ?
" Consider phenolphthalein, rhodamine B, others
! Is dipstick + but no RBC present? " Beware if specific gravity < 1.008 (RBC
may have been there, but lysed) " Usually false positive test " Unfortunately, a common referral
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Hematuria
Evaluation 1: Examine Urine ! Is there pyuria or bacteruria?
" Probable infection (any GU site) ! Is there proteinuria (> 2 + on dipstick), or
are there dysmorphic RBCs or RBC casts? " Probable glomerulonephritis
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Hematuria
Evaluation 2: History and Physical ! Flank Pain
" Stone ! Dysuria, bladder irritability
" Bladder or prostate infection ! Sickle cell, diabetes
" Papillary necrosis ! Family or personal history of calculi,
PCKD, other GU / Neph diseases " Possible familial trait
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Hematuria
Evaluation 2: History and Physical ! Trauma, or intense physical activity
" May be cause of hematuria ! Tobacco use, occupational chemical
exposure (aromatic dyes) " Risk for renal and urothelial cancers
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Hematuria
Evaluation 2: History and Physical ! Visible blood at urethral meatus
" Urethral source ! Fever, CVAT
" Pyelonephritis ! Prostate exam
" Prostatitis, Prostate cancer ! Pelvic Exam
" Urethral, vaginal, or labial lesions
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Hematuria
Evaluation 3: Labs and Procedures ! Formal urinalysis with microscopic
examination ! Urine culture
! If infection is DOCUMENTED, then can omit rest of work-up if hematuria clears with antibiotics
! IVU versus KUB + US versus CT ! +/- Urine cytology ! +/- Serum electrolytes and creatinine ! Cystoscopy
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Hematuria
Diagnostic Categories ! Infection ! Calculi ! Cancer ! Benign neoplasms / lesions ! Other obstruction ! Trauma / exertional hematuria ! Medical renal disease ! Blood dyscrasia / anticoagulation ! Benign familial hematuria
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Hematuria
Infection ! Kidney
! Pyelonephritis - parenchyma ! Pyonephrosis - pus in collecting system ! Renal abscess - pus pocket in
parenchyma
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Hematuria
Infection ! Bladder
! Bacterial cystitis ! Prostate
! Bacterial prostatitis ! Urethra
! Infectious urethritis
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Hematuria
Calculi ! Kidney
! Obstructive vs. Non-obstructive ! Simple vs. Staghorn
! Ureter ! Obstructive vs. Non-obstructive
! Bladder
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Hematuria
Cancer ! Kidney
! Renal cell carcinoma, other ! Upper collecting system
! Urothelial, other ! Bladder
! Urothelial, other ! Urethra
! Squamous cell, other ! Prostate
! Adenocarcinoma, other
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Hematuria
Benign Neoplasms / Lesions ! Kidney
! Simple cysts ! Cystic renal diseases ! Angiomyolipoma, other neoplasms
! Ureter ! Hemangioma, other
! Bladder ! Endometrioma, other
! Urethra ! Condyloma, other
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Hematuria
Other Obstructions ! Ureter
! Ureteropelvic junction (UPJ) ! Intrinsic strictures ! Extrinsic obstruction
! Bladder ! Bladder outlet obstruction (BOO)
– Benign prostatic hyperplasia (BPH) – Other
! Urethra – Strictures, other
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Hematuria
Trauma / Exertional Hematuria ! Cannot be assumed to be cause
Medical Renal Disease ! Previous Nephrology lecture
Blood Dyscrasia / Anticoagulation ! Cannot be assumed to be cause
Benign Familial Hematuria ! Microscopic only, negative work-up
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Kidney & Upper Urinary Tract
Kidney, Intra-renal Collecting System, and Ureter ! Topics covered (case presentations)
! Ureteral obstruction (UPJO) ! Calculi (ureteral, renal) ! Infection (pyelonephritis) ! Cancer (renal cell carcinoma) ! Renal cystic disease (ADPKD)
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Kidney & Upper Urinary Tract: Obstruction
Case 1: Ureteropelvic Junction Obstruction (UPJO) ! 24 year old woman ! Long history of intermittent left flank
pain, recently worsening ! Not during sleep ! Especially notices after fluid intake, or
even more after drinking alcohol ! No significant medical history
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Kidney & Upper Urinary Tract: Obstruction
Case 1: Ureteropelvic Junction Obstruction (UPJO) ! Young age - diagnosed mostly in
children, variable after that ! Intermittent symptoms - typical of adult
presentation ! Pain increased with fluid intake
! Classic for UPJO ! Flow-dependent obstruction (like a
slow but not-yet clogged drain)
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Kidney & Upper Urinary Tract: Obstruction
Anatomy of Kidney and Upper Urinary Tract ! Paired Kidneys ! Urine from collecting tubules that
terminate in papillae drain into: ! Calyces, that coalesce into ! Infundibula, which drain into ! Renal Pelvis
! Travels down ureter (peristalsis)
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Kidney & Upper Urinary Tract: Obstruction
Calyx
Infundibulum
Renal Pelvis
J.S. Wolf
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Kidney & Upper Urinary Tract: Obstruction
Anatomy of Kidney and Upper Urinary Tract ! “Tight spots” prone to obstruction
! Ureteropelvic junction (UPJ) ! Mid-ureter as crosses iliac vessels
(over sacrum on plain radiograph) ! Ureterovesical junction (UVJ)
! Of these, the UPJ most common site of congenital obstruction
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Gray’s Anatomy
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Gray’s Anatomy
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Image removed
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Kidney & Upper Urinary Tract: Obstruction
Case 1: Ureteropelvic Junction Obstruction (UPJO) Evaluation ! Intravenous urogram
! Unilateral hydronephrosis and non-visualization of ureter
! Diuretic renal scintigraphy ! 50% split renal function ! T 1/2 (time for ! of tracer to exit
kidney) on symptomatic side > 100 minutes (normal < 10 minutes)
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Intravenous Urogram Left
hydronephrosis and non-visualization of the ureter
Source Undetermined
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Diuretic Renal Scintigraphy
Excretion from left kidney is delayed Source Undetermined
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Kidney & Upper Urinary Tract: Obstruction
Case 1: Ureteropelvic Junction Obstruction (UPJO) Treatment
! Percutaneous endopyelotomy
! A minimally-invasive alternative to formal pyeloplasty
! Nephro-ureteral stent capped off in 1 week, and removed in 6 weeks
! Complete resolution
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Kidney & Upper Urinary Tract: Obstruction
Causes of UPJO ! Primary
! Histological disorganization – excess longitudinal muscle fibers
(loss of normal organization) – increase in collagen – attenuation of muscle bundles
! Crossing vessels, high insertion, kinks, bands
! Secondary ! Traumatic scar, iatrogenic scar, external
compression (think cancer!)
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Kidney & Upper Urinary Tract: Obstruction
Evaluation of UPJO ! Determine presence and degree of
obstruction ! Is there obstruction, or just dilation? ! Complete or partial obstruction?
! Determine renal function ! If kidney not working well, may be
little value in repairing ! Determine cause of obstruction
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Kidney & Upper Urinary Tract: Obstruction
Dilation of the Urinary Tract ! Non-obstructive
! Ureteral reflux, prior obstruction, extra-renal pelvis, diuresis
! Stagnation may lead to infection and calculi, but usually innocuous
! Obstructive ! Increased resistance to urine flow that
produces increased proximal pressure and subsequent loss of organ function
! Occasionally difficult to distinguish from non-obstructive
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Massive Vesico-ureteral Reflux on Cystogram
Source Undetermined
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Kidney & Upper Urinary Tract: Obstruction
Evaluation of UPJO ! Anatomic tests
! Intravenous urography ! Renal (surface) ultrasonography ! Computed tomography ! Endoluminal ultrasonography
! Functional tests ! Ultrasonography with resistive indices ! Diuretic renal scintigraphy ! Whitaker test
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Intravenous Urography
Normal kidney
Hydronephrosis
Source Undetermined
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Renal Ultrasonography Hydronephrosis
Source Undetermined
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Computed Tomography Can determine additional anatomy, including vessels crossing at UPJ
Source Undetermined
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Computed Tomography Can determine additional anatomy, including vessels crossing at UPJ
Source Undetermined
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Endoluminal Ultrasonography Can detect vessels crossing over UPJ, but requires retrograde catheterization
Source Undetermined
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Ultrasonography with Resistive Indices (PSV - LDV) /PSV: Normal
Diastolic flow velocity is preserved Source Undetermined
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Ultrasonography with Resistive Indices (PSV - LDV) /PSV: Obstructed
As resistance to blood flow increases, diastolic flow velocity decreases, and resistive index increases (R.I. > 0.70)
Source Undetermined
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Diuretic Renal Scintigraphy: most definitive non-invasive test T ! = Time for ! of radiotracer to be excreted from kidney after furosemide
T ! = 5 minutes (normal < 10 min.) T ! = 25 minutes
(obstructed > 15 min.) Sources Undetermined
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Whitaker Test: most definitive test Pressure in renal pelvis at set infusion rate through nephrostomy tube (> 15 mmHg at 15 cc/min infusion = obstruction)
Source Undetermined
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Kidney & Upper Urinary Tract: Obstruction
Treatment of UPJO ! Open pyeloplasty
! Laparoscopic pyeloplasty
! Percutaneous endopyelotomy
! Retrograde balloon dilation ! Retrograde endopyelotomy ! Acucise® (cutting balloon) endopyelotomy
Most Invasive / Most
Effective
Least Invasive / Least
Effective
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Break
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Kidney & Upper Urinary Tract: Calculi
Case 2: Acutely Obstructing Distal Ureteral Calculus ! 30 year old man ! Sudden onset of right flank pain ! Initial gross hematuria, but now clear ! No fevers and chills, but nausea ! Frequent urination ! Pain somewhat less after a few hours ! Restless, moving about ! Right flank, lower quadrant, and testicular
pain / tenderness ! 5 - 10 RBC / hpf on urinalysis
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Kidney & Upper Urinary Tract: Calculi
Case 2: Acutely Obstructing Distal Ureteral Calculus ! Sudden onset pain - c/w renal colic ! Urine cleared - suggests obstruction ! Nausea - very common with renal colic ! Freq. urination - irritation by distal calculi ! Pain decreased - forniceal rupture, decrease in
pressure from renal hemodynamics ! Moving about - NOT peritonitis ! Flank to scrotum - expected radiation ! Urinalysis - RBCs in 85%
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Kidney & Upper Urinary Tract: Calculi
Suspected Acute Ureteral Obstruction Differential Diagnosis
! Intrinsic ! Calculi, tumor, clot, edema
! Extrinsic ! Compression by tumor, lymph node
! Acute versus acute-on-chronic ! Calculi, or calculi impacted into partially-
obstructing stricture? ! Clot, or clot on tumor?
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Kidney & Upper Urinary Tract: Calculi
Suspected Acute Ureteral Obstruction Radiographic Evaluation
! KUB and Intravenous urography ! Anatomic picture, localize pathology
! Ultrasonography ! CT
! Non-contrast (stones) ! CT urogram (with contrast, like IVU)
! Retrograde pyelography ! Injection through catheter
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Intravenous Urography This stone
is less dense than contrast material, so appears as filling defect
Source Undetermined
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Intravenous Urography
This stone is faintly radio-opaque …
Source Undetermined
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Intravenous Urography
… and is easier to identify when contrast material comes down to it
Source Undetermined
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Kidney & Upper Urinary Tract: Calculi
Spontaneous Passage of Ureteral Stones
Width Proximal Middle Distal 4 mm 20% 45% 55% 5 mm 6% 30% 45% 6 mm 0% 10% 25%
1 2 3 4 5 6 7 8 9 100%
50%
100%
1 2 3 4 5 6 7 8 9 10
J.S. Wolf
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Ultrasonography
Hydronephrosis Source Undetermined
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Computed Tomography (almost) all stones dense on CT
Source Undetermined
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Computed Tomography
Secondary signs of ureteral obstruction Source Undetermined
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Computed Tomography
Secondary signs of ureteral obstruction Source Undetermined
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Computed Urography
Source Undetermined
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Intravenous Urography
Irregular Filling Defect
Source Undetermined
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Kidney & Upper Urinary Tract: Calculi
If “filling defect” on contrast study … ! Neoplasm
! Urothelial neoplasm most common ! Blood clot
! Will resolve during follow-up ! “Radio-lucent” calculus (15%)
! Other 85% are calcium containing ! Refers to appearance on plain film (all
typical stones are opaque on CT scan) ! Radio-lucent stones are usually uric acid
(only medically dissolvable stone) ! Need to rule-out tumor!
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Kidney & Upper Urinary Tract: Calculi
Case 3: Non-obstructing Renal Calculus ! 65 year old man ! Microscopic hematuria ! Remote history of urolithiasis ! Mild prostatism ! Unremarkable PE except for prostatic
enlargement ! Urinalysis - 10 RBC / hpf
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Plain Radiography
Densely radio-opaque stones
Source Undetermined
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Kidney & Upper Urinary Tract: Calculi
Indications for Surgical Treatment of Urolithiasis ! Urinary tract infection ! Significant obstruction ! Pain refractory to oral medication ! Others
! Staghorn calculi - risk of urosepsis ! Long-standing ureteral calculi - eventual
obstruction ! Occupational or lifestyle reasons
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Plain Radiography
Staghorn Calculus
Source Undetermined
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Kidney & Upper Urinary Tract: Calculi
Surgical Treatment of Urolithiasis ! Open surgical / laparoscopic lithotomy
! Percutaneous nephrostolithotomy
(Antegrade endoscopy) ! Ureteroscopy (Retrograde endoscopy)
! Extracorporeal shock wave lithotripsy (SWL)
Most Invasive / Most
Effective
Least Invasive / Least
Effective
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Source Undetermined
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Source Undetermined
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Image removed
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Source Undetermined
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Source Undetermined
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Source Undetermined
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Kidney & Upper Urinary Tract: Calculi
Parameters Determining Treatment of Urolithiasis ! Size ! Location ! Composition ! Medical Condition, Patient Preference,
Physician Preference
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Kidney & Upper Urinary Tract: Calculi
Size ! Small
! SWL ! Moderate
! Ureteroscopy ! Large
! Percutaneous nephrostolithotomy
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Kidney & Upper Urinary Tract: Calculi
Location ! Distal Ureter
! Scope > SWL ! Middle Ureter
! Scope > SWL ! Proximal Ureter
! SWL > Scope ? ! Kidney
! SWL > Scope
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Computed Tomography
Distal aspect of UVJ, almost in bladder Source Undetermined
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Computed Tomography
Huge bilateral renal calculi Source Undetermined
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Kidney & Upper Urinary Tract: Calculi
Composition ! Dense (Calcium oxalate monohydrate)
! Scope ! Fuzzy/ Faint (Calcium oxalate dihydrate,
calcium phosphate, struvite) ! SWL
! Cystine ! Scope
! Uric Acid ! SWL
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Plain Radiography
Densely radio-opaque stone
Source Undetermined
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Plain Radiography
“Fuzzy” radio-opaque stone
Source Undetermined
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Kidney & Upper Urinary Tract: Pyelonephritis
Case 4: Pyelonephritis ! 29 year old woman ! Started with 3 days of dysuria (painful
urination), urinary frequency / urgency ! Now temp 101.7º C, right flank pain ! History
! Occ previous UTI ! Recently married ! Limited sexual activity before marriage,
now active ! PE - Right CVAT
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Kidney & Upper Urinary Tract: Pyelonephritis
Case 4: Pyelonephritis ! Young woman - UTI is common ! Initial cystitis (infection ascends) common
and suggest UTI ! Systemic symptoms - distinguishes upper
from lower tract UTI ! Previous UTI - helps establish her
characteristic symptoms of UTI ! Sexual activity - predisposing factor for
UTI in women ! CVAT - renal involvement
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Kidney & Upper Urinary Tract: Pyelonephritis
Acute Pyelonephritis ! Most common disease of the kidney ! Usually ascending infection ! Diagnosis by clinical findings and urine
culture (85% are GNR; E. Coli) ! Imaging used to detect complications or
to assess for predisposing factors ! Complications: papillary necrosis,
pyonephrosis, abscess, sepsis ! Predisposing factors: obstruction, calculi,
vesico-ureteral reflux
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Lobar Nephronia Source Undetermined
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Kidney & Upper Urinary Tract: Pyelonephritis
Management of Acute Pyelonephritis ! Typical case - fever resolves within 48 hrs
of starting antibiotics ! Oral abx in most ! Intravenous abx if very ill-appearing
! Debilitated patients at greater risk ! Diabetes mellitus ! Steroids ! Chronically ill ! Immuno-suppressed
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Kidney & Upper Urinary Tract: Pyelonephritis
Management of Acute Pyelonephritis ! History of complications or lack of
response to antibiotics " US or CT for obstruction, calculi
! Upper tract obstruction with infection " DRAINAGE (stent, percutaneous tube)
! Upper tract calculus with infection " Treat acute infection, then calculus
! If child or recurrent " US for scars " Voiding cystogram for reflux
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Kidney & Upper Urinary Tract: Pyelonephritis
Drainage procedures ! Percutaneous nephrostomy tube
! Ureteral stent
Hildpeyi, wikimedia commons
Image of a percutaneous nephrostomy tube removed
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Break
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Kidney & Upper Urinary Tract: Masses & Cysts
Case 5: Renal Cell Carcinoma (RCC) ! 64 year old man ! Gross hematuria ! Flank pain ! History
! 66 pack-year smoker ! PE
! Fullness in right flank
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Kidney & Upper Urinary Tract: Masses & Cysts
Case 5: Renal Cell Carcinoma (RCC) ! Older man - peak in 6th decade, 3:1
M:F overall ! Hematuria - most common presenting
sign ! Flank pain and flank mass - along with
hematuria, the classic triad ! Smoking - major acquired risk factor
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SEER Cancer Statistics
Kidney & Upper Urinary Tract: Masses & Cysts
Demographics of RCC ! Incidence: 12.8 per 100,000 (‘00 - ‘04) ! Mortality: 4.2 per 100,000 (‘00 - ‘04) ! estimated 51,190 new cases in 2007
(~2% of adult malignancies) ! estimated 12,890 deaths in 2007 ! Lifetime Risk (M / F)
! Risk of occurrence - 1.71 / 1.01 % ! Risk of death - 0.59 / 0.35 %
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Kidney & Upper Urinary Tract: Masses & Cysts
Risk factors for RCC ! Cigarettes ! Obesity ! Hypertension ! Occupational exposures ! Dialysis ! Hereditary
! von Hippel-Lindau disease ! Tuberous Sclerosis
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Kidney & Upper Urinary Tract: Masses & Cysts
Pathology of RCC ! Proximal tubular cell neoplasm ! Often venous involvement ! Hemorrhagic, necrotic, cystic, and
calcified components common ! Metastasize most commonly to lung,
liver, bone, adrenal, and contralateral kidney
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Kidney & Upper Urinary Tract: Masses & Cysts
Common Renal Tumors
Pathology Malignant? Relative % Renal Cell Ca. Yes 85%
Urothelial Ca. Yes 5%
Oncocytoma No 5%
Other Most not 5%
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Kidney & Upper Urinary Tract: Masses & Cysts
Histology
! Most Renal Cell Carcinomas have “Clear cell” histology
! Lipids (dissolve out during slide processing) and glycogen
! Fuhrman grading (1 to 4)
– 1 = well differentiated
– 4 = poorly differentiated
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Kidney & Upper Urinary Tract: Masses & Cysts
Genetics ! Most renal cell carcinomas are sporadic ! Are associated with several syndromes,
the most common of which is Von-Hippel Lindau syndrome ! Autosomal dominant ! Cerebellar and retinal vascular tumors ! Adrenal and renal tumors (inc cysts)
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Kidney & Upper Urinary Tract: Masses & Cysts
Genetics ! Von-Hippel Lindau syndrome
! Autosomal dominant ! Mutation in VHL tumor suppressor
gene: 3p25-26 ! 95% of sporadic “clear cell” renal cell
carcinomas have VHL mutation ! One of the strongest associations
among solid tumors ! Opportunities for gene therapy
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Kidney & Upper Urinary Tract: Masses & Cysts
Symptoms / Signs of RCC
! Hematuria (29 – 60%)
! Flank pain (14 – 51%)
! Flank mass (21 – 47%) ! All 3 = Classic triad
! Present in < 10% ! Usually signifies advanced disease
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Kidney & Upper Urinary Tract: Masses & Cysts
Paraneoplastic Syndromes ! ESR elevation ! Calcium elevation ! Polycythemia ! Anemia ! Thrombophlebitis ! Hyperinsulinism ! LFT elevation
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Kidney & Upper Urinary Tract: Masses & Cysts
Central Role of Imaging
Simple Cyst Benign
Indeterminate Cyst
Solid Mass Malignant
?
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Kidney & Upper Urinary Tract: Masses & Cysts
Stage Migration of RCC due to more frequent imaging ! 1970’s
! 4% of RCC < 3 cm ! 32% presented with metastases
! 1980’s ! 25 - 40% were incidental finding ! 25% of RCC < 3 cm ! 17% presented with metastases
! 1990’s ! 60% were incidental finding
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Kidney & Upper Urinary Tract: Masses & Cysts
Imaging Modalities
! Intravenous Urography (IVU, IVP)
! Ultrasonography (US)
! Computed Tomography (CT)
! Magnetic Resonance Imaging (MRI)
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Kidney & Upper Urinary Tract: Masses & Cysts
Intravenous Urography ! Typical upper tract imaging for hematuria
work-up ! Excellent visualization of collecting system ! Renal mass or cyst causes displacement
of surrounding organ or deformation of outline
! Screening study only ! If renal mass / cyst suspected, further
imaging is required
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Intravenous Urography
Mass Effect in kidney
Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Ultrasonography ! Usual follow-up to IVU suspicious for
renal mass / cyst ! No ionizing radiation ! Non-invasive ! Operator dependent ! Reliably identifies simple cyst (85% of
renal mass / cysts) ! If NOT a simple cyst
! Cross-sectional imaging
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Ultrasonography
Simple Cyst Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Sonographic Characteristics ! Anechoic with enhanced through
transmission ! Simple cyst
! Echogenic with acoustic shadowing ! Stone or other calcification
! Iso / hypoechoic mass ! Solid mass
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Ultrasonography
Renal Stone Source Undetermined
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Ultrasonography
Nodule in Cyst Source Undetermined
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Ultrasonography
Solid Mass Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Computed Tomography ! Current gold standard ! Non-contrast scan, then scan with
intravenous contrast ! Enhancement = Hounsfield units
(density) increase by > 10 with contrast
! 3 to 5 mm maximum cut width ! Spiral CT - single breath hold
! Minimize motion artifact ! Exact duplication of cuts
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Computed Tomography
Simple Cyst Source Undetermined
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Computed Tomography
Complex Cyst Source Undetermined
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Renal Cell Carcinoma
Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Solid, Enhancing Renal Mass on CT is RCC until Proven Otherwise ! Other possibilities
! Oncocytoma – Benign, but indistinguishable from
RCC on imaging ! Angiomyolipoma
– Benign, but can bleed if large – Usually diagnosed by imaging fat
! Inflammatory mass – History of febrile illness
! Lymphoma – Malignant, but no surgery
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Oncocytoma ? Source Undetermined
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Angiomyolipoma
Source Undetermined
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Renal Abscess
Source Undetermined
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Renal Lymphoma
Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Magnetic Resonance Imaging ! Currently no advantage over CT except
in certain situations ! Allergy to contrast material ! Elevated creatinine ! Distinguish wall in some cysts ! Detection of venous tumor thrombus
in RCC (has replaced invasive venography)
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Magnetic Resonance Imaging
Thick Cyst Wall Source Undetermined
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Magnetic Resonance Imaging
Tumor Thrombus in Vena Cava
Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Sensitivity for Diagnosis of RCC < 3 cm
! Intravenous urography - 67%
! Ultrasonography - 79%
! Computed tomography - 94%
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Kidney & Upper Urinary Tract: Masses & Cysts
Evaluation of Suspected RCC
! Initial imaging study (often IVU or US, either incidentally or for workup of hematuria or other signs / symptoms)
! CT or MRI for local assessment ! Define lesion ! Assess nodes, vein, other organs
! Staging ! CXR, Bloods, + Bone Scan and others
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Kidney & Upper Urinary Tract: Masses & Cysts
Staging and Management of RCC ! Stage I
! Tumor < 7 cm limited to kidney (T1) ! no LN+ or metastases " Radical or Partial Nephrectomy
! Stage II ! Tumor > 7 cm limited to kidney (T2) ! No LN+ or metastases " Radical Nephrectomy
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Kidney & Upper Urinary Tract: Masses & Cysts
Staging and Management of RCC ! Stage III
! Tumor into vein, fat, or adrenal ! Or one single LN+ " Radical Nephrectomy
! Stage IV ! Tumor beyond Gerota’s fascia (T4) ! Or > 1 LN+ Or metastases " Systemic Therapy (Chemo, Immuno)
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Kidney & Upper Urinary Tract: Masses & Cysts
Prognosis of RCC 5 year survival
! Stage I ~90% ! Stage II ~80% ! Stage III ~40 - 60% ! Stage IV ~10%
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Kidney & Upper Urinary Tract: Masses & Cysts
Case 6: Autosomal Dominant Polycystic Kidney Disease (ADPKD) ! 37 year old woman ! No recent medical care ! Left flank “fullness” ! Adopted, unknown family history ! PE
! Mass in left flank ! BP 170/100
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Kidney & Upper Urinary Tract: Masses & Cysts
Case 6: Autosomal Dominant Polycystic Kidney Disease (ADPKD) ! Middle-aged - usually diagnosed in third
decade ! “Fullness” - HUGE bilateral cysts,
symptomatic in ~15% ! Over 50% have family history ! Hypertension - almost always, given
enough time
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Kidney & Upper Urinary Tract: Masses & Cysts
ADPKD
! Autosomal dominant inheritance
! 85% from PKD1 mutation (16q13)
! 15% from PKD2 mutation (4q21-23)
! Virtually 100% penetrance
! Incidence
! 1 / 1000 live births
! 6000 new cases annually
! Prevalence ~ 200,000
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Kidney & Upper Urinary Tract: Masses & Cysts
ADPKD
! Epithelial proliferation in renal tube ! renal tubule become cyst ! as cyst grows it compresses renal parenchyma
! < 1% tubules become cysts
! Also hepatic, pancreatic and splenic cysts, and cerebral aneurysms
! Hypertension
! Renal failure - most but not all, usually in 5th decade
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ADPKD
Source Undetermined
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Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Other Cystic Diseases of the Kidney ! Simple cysts
! In population over age 50 – 50% pathologically, 33% by CT
! Single or multiple ! Simple cyst complicated by hemorrhage or
infection (“Complex cyst”) ! Acquired cystic kidney disease (ACKD)
! 40% of dialysis patients by 3 years ! Controversial increase in RCC
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ACKD
Source Undetermined
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Kidney & Upper Urinary Tract: Masses & Cysts
Evaluation of Renal Cysts ! Simple cysts definable with US
! No further work-up needed ! ADPKD, ACKD
! Definable by history and PE ! “Complex Cyst”
! Simple cyst complicated by infection or hemorrhage
! Cystic renal cancer ! Diagnostic dilemma, surgery often
required
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Slide 28: Stuart Wolf Slide 30: Gray’s Anatomy Slide 31: Gray’s Anatomy Slide 34: Source Undetermined Slide 35: Source Undetermined Slide 40: Source Undetermined Slide 42: Source Undetermined Slide 43: Source Undetermined Slide 44: Source Undetermined Slide 45: Source Undetermined Slide 46: Source Undetermined Slide 47: Source Undetermined Slide 48: Source Undetermined Slide 49: Source Undetermined Slide 50: Source Undetermined Slide 57: Source Undetermined Slide 58: Source Undetermined Slide 59: Source Undetermined Slide 60: Stuart Wolf Slide 61: Source Undetermined Slide 62: Source Undetermined Slide 63: Source Undetermined Slide 64: Source Undetermined Slide 65: Source Undetermined Slide 66: Source Undetermined Slide 69: Source Undetermined Slide 71: Source Undetermined
Additional Source Information for more information see: http://open.umich.edu/wiki/CitationPolicy
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Slide 73: Source Undetermined Slide 74: Source Undetermined Slide 76: Source Undetermined Slide 77: Source Undetermined Slide 78: Source Undetermined Slide 82: Source Undetermined Slide 83: Source Undetermined Slide 85: Source Undetermined Slide 86: Source Undetermined Slide 90: Source Undetermined Slide 93: Hildpeyi, Wikimedia Commons, http://commons.wikimedia.org/wiki/File:Ureteral_stent.jpg, CC:BY-SA,
http://creativecommons.org/licenses/by-sa/3.0/deed.en Slide 110: Source Undetermined Slide 112: Source Undetermined Slide 114: Source Undetermined Slide 115: Source Undetermined Slide 116: Source Undetermined Slide 118: Source Undetermined Slide 119: Source Undetermined Slide 120: Source Undetermined Slide 122: Source Undetermined Slide 123: Source Undetermined Slide 124: Source Undetermined Slide 125: Source Undetermined Slide 127: Source Undetermined Slide 128: Source Undetermined Slide 138: Source Undetermined Slide 139: Source Undetermined Slide 141: Source Undetermined