uroradiology ayşegül sarsilmaz m.d. radiology. radiological modalities ultrasound ultrasound...

URORADIOLOGYURORADIOLOGY

Ayşegül SARSILMAZ M.D.Ayşegül SARSILMAZ M.D.

RadiologyRadiology

Radiological ModalitiesRadiological Modalities

UltrasoundUltrasound Intravenous PyelographyIntravenous Pyelography Computed TomographyComputed Tomography Magnetic Resonance ImagingMagnetic Resonance Imaging Radionuclide ScanningRadionuclide Scanning

UltrasoundUltrasound

CT (-) CT (-) Anatomical info. Anatomical info.

MRIMRI

Radionuclide Radionuclide Functional info. Functional info.

IVP IVP Anatomical + Anatomical + Fnx.Fnx.

ULTRASOUNDULTRASOUND

First line investigation !!!First line investigation !!! Provides anatomical information Provides anatomical information

without ionizing radiationwithout ionizing radiation No need for intravenous contrast No need for intravenous contrast

!!!!!!

INDICATIONS (USG)INDICATIONS (USG)

İnvestigate patients with İnvestigate patients with symptoms thought to arise from symptoms thought to arise from UTUT

Size of the kidneysSize of the kidneys Presence of hydronephrosisPresence of hydronephrosis Renal tumors, cysts, abcessesRenal tumors, cysts, abcesses Assess bladder and prostateAssess bladder and prostate

Normal FindingsNormal Findings

Kidneys; smooth in outlineKidneys; smooth in outline Central echogenic region (renal sinus)Central echogenic region (renal sinus) Renal cortex (hypoechoic)Renal cortex (hypoechoic) Pyramids (triangular hypoechoic areas)Pyramids (triangular hypoechoic areas) Size : 90-120 mm Size : 90-120 mm Urinary Bladder : examined in Urinary Bladder : examined in

distended state, imperceptible walls, distended state, imperceptible walls, anechoic lumenanechoic lumen

Intravenous PyelographyIntravenous Pyelography

Largely replaced by USLargely replaced by US 50-100 ml of contrast is injected intravenously50-100 ml of contrast is injected intravenously Carried via blood to the kidneys, passes Carried via blood to the kidneys, passes

through the glomerular filtrate through the glomerular filtrate collecting collecting systemssystems

Main indications:Main indications: Detailed demonstration of PCS and uretersDetailed demonstration of PCS and ureters Acute ureteric colicAcute ureteric colic Investigation of renal calculiInvestigation of renal calculi Investigation of hematuriaInvestigation of hematuria

First step: Plain filmFirst step: Plain film Look at renal contourLook at renal contour Identify all calcifications !!!Identify all calcifications !!!

Urinary calculi Urinary calculi (kidney,ureter,bladder)(kidney,ureter,bladder)

NephrocalcinosisNephrocalcinosis Prostatic calcificationProstatic calcification

Kidneys:Kidneys: position , length , contours position , length , contours Calices:Calices: should be symmetrical, cup- should be symmetrical, cup-

shaped.shaped. If dilated If dilated club-shaped (due to club-shaped (due to

obstruction or destruction of papilla)obstruction or destruction of papilla) Renal pelvis and ureters:Renal pelvis and ureters: normal pelvis is normal pelvis is

funnel-shaped, ureters are seen in only funnel-shaped, ureters are seen in only part of their length due to peristaltism.part of their length due to peristaltism.

Bladder:Bladder: centrally located, smooth centrally located, smooth outline, should be empty after micturitionoutline, should be empty after micturition

Computed TomographyComputed Tomography

Indications:Indications: To characterize renal masses and stage To characterize renal masses and stage

tumorstumors To diagnose or exclude renal traumaTo diagnose or exclude renal trauma To demonstrate stonesTo demonstrate stones To assess acute ureteric colicTo assess acute ureteric colic To delineate renal vascular anatomyTo delineate renal vascular anatomy

Normal FindingsNormal Findings

Renal sinus ; low attenuation in the Renal sinus ; low attenuation in the centercenter

There should not be any calcificationThere should not be any calcification Ureters are seen as dots in cross Ureters are seen as dots in cross

section lying on the psoas musclessection lying on the psoas muscles Bladder has a smooth outline, thin Bladder has a smooth outline, thin

wall, anechoic urine.wall, anechoic urine. Axial images may be reformatted in Axial images may be reformatted in

the coronal and sagittal planesthe coronal and sagittal planes

MRIMRI

Used in selected circumstances Used in selected circumstances (renal artery stenosis, IVCal (renal artery stenosis, IVCal

extension of renal tumors)extension of renal tumors)

Voiding Voiding CystourethrogramCystourethrogram

Bladder is filled with contrast Bladder is filled with contrast medium through a catheter and medium through a catheter and films are taken during voiding films are taken during voiding

Observed fluoroscopically to identify Observed fluoroscopically to identify reflux of contrast medium from reflux of contrast medium from bladder to upper UT.bladder to upper UT.

Risk of urinary tract infection, Risk of urinary tract infection, chronic pyelonephritis and renal chronic pyelonephritis and renal scarring is increased in VUR. scarring is increased in VUR.

Grading of VURGrading of VUR

Grade 1 reflux of urine only into the Grade 1 reflux of urine only into the ureterureter

Grade 2 reflux into the pelvis and calices, Grade 2 reflux into the pelvis and calices, no dilatationno dilatation

Grade 3 mild to moderate dilatation of Grade 3 mild to moderate dilatation of the ureters and renal pelvisthe ureters and renal pelvis

Grade 4 moderate dilatation and Grade 4 moderate dilatation and tortuosity of the ureters,pelvis,calicestortuosity of the ureters,pelvis,calices

Grade 5 gross dilatation and tortuosity of Grade 5 gross dilatation and tortuosity of the ureters,pelvis and calicesthe ureters,pelvis and calices

UPPER URINARY TRACT UPPER URINARY TRACT DISORDERSDISORDERS

Urinary CalculiUrinary Calculi Urinary Tract ObstructionUrinary Tract Obstruction Renal Parenchymal MassesRenal Parenchymal Masses Urothelial TumorsUrothelial Tumors Acute Pyelonephritis, Perinephric Acute Pyelonephritis, Perinephric

abscessabscess Chronic PyelonephritisChronic Pyelonephritis Congenital AnomaliesCongenital Anomalies

LOWER URINARY TRACT LOWER URINARY TRACT DISORDERSDISORDERS

Bladder TumorsBladder Tumors Bladder DiverticulaBladder Diverticula Prostatic EnlargementProstatic Enlargement

Urinary CalculiUrinary Calculi

Most calculi are calcified and can be Most calculi are calcified and can be seen as radiodense on plain x-ray.seen as radiodense on plain x-ray.

Only pure uric acid and xanthine Only pure uric acid and xanthine stones are radiolucent on plain stones are radiolucent on plain radiography, and they can be radiography, and they can be identified at CT or US.identified at CT or US.

US ; hyperechoic with posterior US ; hyperechoic with posterior acoustic shadowingacoustic shadowing

CT ; hyperdense CT ; hyperdense

Urinary Tract Urinary Tract Obstruction Obstruction

The main feature is dilatation of the The main feature is dilatation of the pelvicaliceal system and ureterspelvicaliceal system and ureters

Main causes : Main causes : CalculiCalculi Blood clotBlood clot Sloughed papillaSloughed papilla Tumors Tumors

US, IVP and CTUS, IVP and CT

US : dilatation of PCS is seen as US : dilatation of PCS is seen as multiloculate fluid collection in the multiloculate fluid collection in the central echo complex (caused by central echo complex (caused by pooling of urine within the distended pooling of urine within the distended pelvis and calices). Proximal ureteric pelvis and calices). Proximal ureteric dilatation can also be demonstrated dilatation can also be demonstrated but overlying bowel gas obscures but overlying bowel gas obscures dilatation of the mid and distal dilatation of the mid and distal ureter.ureter.

IVPIVP

Plain films may be helpful to Plain films may be helpful to demonstrate the calculusdemonstrate the calculus

Delayed films are essentialDelayed films are essential Filling of the pelvicaliceal system Filling of the pelvicaliceal system

with contrast medium is greatly with contrast medium is greatly delayed.delayed.

CTCT

In acute obstruction, non-contrast In acute obstruction, non-contrast CT demonstrates the calculi.CT demonstrates the calculi.

Renal Parencymal Renal Parencymal MassesMasses

Causes: cyst, benign tumor Causes: cyst, benign tumor (angiomyolipoma), renal cell (angiomyolipoma), renal cell carcinoma, metastases, abscesscarcinoma, metastases, abscess

US US usually renal masses are first detected by usually renal masses are first detected by

US.US. Cystic versus SolidCystic versus Solid Simple cyst: common in elderly, solitary or Simple cyst: common in elderly, solitary or

multiple, unilocular or septated. Acoustic multiple, unilocular or septated. Acoustic enhancement.enhancement.

Angiomyolipoma: small echogenic Angiomyolipoma: small echogenic masses.masses.

Renal Cell CarcinomaRenal Cell Carcinoma

RCCs account for 86% of all primary RCCs account for 86% of all primary renal parenchymal tumors.renal parenchymal tumors.

On US; solid tumorsOn US; solid tumors May be iso, hypo or hyperechoic.May be iso, hypo or hyperechoic. When a tumor is demonstrated, When a tumor is demonstrated,

extension into the renal vein and extension into the renal vein and inferior vena cava should be inferior vena cava should be assessed. assessed.

CT CT

Useful for diagnosis and staging of Useful for diagnosis and staging of renal tumorsrenal tumors

Shows local direct spread, Shows local direct spread, enlargement of lymph nodes, liver or enlargement of lymph nodes, liver or other organ metastases, renal vein other organ metastases, renal vein and IVC involvement.and IVC involvement.

Urothelial tumors are seen as filling Urothelial tumors are seen as filling defects in the renal pelvis and defects in the renal pelvis and uretersureters

Filling defects in the collecting Filling defects in the collecting system: calculi, blood clot, tumorsystem: calculi, blood clot, tumor

They may obstruct the ureter and They may obstruct the ureter and cause hyrdonephrosis.cause hyrdonephrosis.

Congenital AnomaliesCongenital Anomalies

Bifid Collecting SystemBifid Collecting System Ectopic KidneyEctopic Kidney Horseshoe kidneyHorseshoe kidney Renal AgenesisRenal Agenesis

Bifid Collecting SystemBifid Collecting System

Most frequent congenital variationMost frequent congenital variation Unilateral or bilateralUnilateral or bilateral Bifid pelvis ................ureteric Bifid pelvis ................ureteric

duplicationduplication

Ectopic KidneyEctopic Kidney

During fetal development kidneys During fetal development kidneys ascend in the abdomenascend in the abdomen

Ectopic kidney results when this Ectopic kidney results when this ascent is haltedascent is halted

In some cases kidneys lie on the In some cases kidneys lie on the same side and are fused (crossed same side and are fused (crossed fused ectopia)fused ectopia)

Horseshoe KidneyHorseshoe Kidney

The kidneys may fail to seperate, The kidneys may fail to seperate, giving rise to a horseshoe kidneygiving rise to a horseshoe kidney

Lower poles are fused by Lower poles are fused by parenchyma or fibrous tissueparenchyma or fibrous tissue

Bladder Tumor Bladder Tumor Most frequent site for neoplasms of Most frequent site for neoplasms of

the urinary tractthe urinary tract On US; bladder tumors are seen as On US; bladder tumors are seen as

soft tissue masses protruding into soft tissue masses protruding into the bladder.the bladder.

IVP; filling defect in the bladderIVP; filling defect in the bladder On CT and MRI; soft tissue mass On CT and MRI; soft tissue mass

projecting from the bladder wallprojecting from the bladder wall

Bladder DiverticulaBladder Diverticula

May be congenital or secondary to May be congenital or secondary to chronic obstruction chronic obstruction

Demonstrated by US, CT or MRI.Demonstrated by US, CT or MRI.

Prostate ImagingProstate Imaging

Prostatic enlargement : benign Prostatic enlargement : benign prostatic hypertrophy, prostatic prostatic hypertrophy, prostatic carcinomacarcinoma

Prostatic ultrasound; transducer Prostatic ultrasound; transducer introduced into the rectumintroduced into the rectum

TRUS guided biopsyTRUS guided biopsy MRI ; tumor is seen mostly in the MRI ; tumor is seen mostly in the

peripheral zone as hypointense on T2peripheral zone as hypointense on T2

Scrotal SwellingScrotal Swelling

US, Color Doppler US, MRIUS, Color Doppler US, MRI Testicular tumor, orchitis-epididymo-Testicular tumor, orchitis-epididymo-

orchitis, testicular torsion, orchitis, testicular torsion, hydrocele ......hydrocele ......

Doppler ; used in Doppler ; used in acute scrotumacute scrotum; to ; to differentiate between epididiymo-differentiate between epididiymo-orchitis and testicular torsionorchitis and testicular torsion Epididiymo-orchitis ; medical treatmentEpididiymo-orchitis ; medical treatment Torsion ; surgery Torsion ; surgery

uroradiology ayşegül sarsilmaz m.d. radiology. radiological modalities ultrasound ultrasound...

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