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Radiology of urogenital systsm slide share

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it is general description of urinary system on imaging

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Radiology of urogenital systsm slide share

  1. 1. Dr Rekha Khare MD Radiology
  2. 2. Part one--contents  General  Imaging modality  IVP  Congenital lesion
  3. 3. Urinary system  The kidneys are retroperitoneal organs to do --- electrolyte homeostasis and waste excretion  Ureters course inferiorly into the pelvis and enter the urinary bladder  In urinary bladder the urine is temporarily stored until it is cleared through the urethra.
  4. 4.  The adrenal, or suprarenal glands are related to the kidneys because of close proximity to renal system  But they produce steroids (cortex) and catecholamines (medulla) so not directly related to renal function
  5. 5. urinary system
  6. 6. Male genitalia and urethera  Prostate has roughly the shape of an inverted rounded cone/ pyramid  Seminal vesicles are paired lobulated sacs about 5cm long in young, run infero medially to join with vas deference to form ejeculatory duct which pierce prostate to enter the prostatic urethra  Male urethera runs from bladder neck to external meatus
  7. 7. Prostate TRUS P/A
  8. 8. Male urethera  It has three section: 1.prostatic- widest part has mound/verumontem along posterior wall 2. membranous-shortest part least distensible 3.penile sudivides into bulbar and distal pendulous part
  9. 9. Scrotum : It is a pouch of skin divided in to two compartment by midline fibrous septum. each compartment contains testes,epididmys and spermatic cord Scrotum on U/S
  10. 10. Embryology of renal system pronephros, mesonephros, and metanephros come in succession  The pronephros develops in the third week of life, and regresses after inducing the maturation of the mesonephros during the fourth to eighth weeks  The mesonephros, serves as excretory function during these weeks, quickly regresses.  Its remnant is the Wolfiann duct, which, in males, develops into the efferent ductules of the testes, the epididymis, and the vas deferens; in females, the epio ophoron and the paro ophoron.
  11. 11. Metanephros  The metanephros forms from two separate cell lines, the ureteric bud and the metanephric blastema.  The ureteric bud develops into the collecting system, including the ureter, renal pelvis, major and minor calyces, and the collecting tubules of the renal medulla  The metanephric blastema develops into the excretory portion of the kidney—the renal cortex, including the Bowman’s capsule (glomerulus, nephron), proximal and distal convoluted tubules, loop of Henle, and the renal parenchymal (supporting) tissues.
  12. 12. Imaging modality  Plain film/KUB  Intravenous pyelography-classic routine exam  Ultrasound  Direct contrast investigation- Retrograde pyelography Antegrade pyelography  Cystography  Cysto urethrography  Urethrography  CT scan  MRI  Renal angiography
  13. 13. Approach to a case of renal problem  Ultrasound KUB region  Depending on finding x-ray KUB or NCCT  IVP to assess renal function or level of obstruction  For renal mass - CECT abdomen
  14. 14. Intravenous pyelography  Classic routine investigation  With the advent of ultrasound its role is now much diminished  Main indication: persistent or frank haematuria renal and ureteric calculi ureteric fistula stricture complex urinary tract infection
  15. 15. Intravenous pyelography  It consists of a series of plain films taken after administration of intravenous injection of water soluble iodine / contrast medium  Traditionally patient is prepared with a period of 4-6 hrs starvation and fluid deprivation and bowel preparation with a strong laxative  Classical series of plain films 5 and 15mts, full length release and full bladder and post micturition.  It can be modified to deal particular circumstances
  16. 16. How to calculate dose of contrast  Standard dose in adult is 50ml of 350-370 strength of water soluble contrast **How much contrast needed for 60kg man ? 300mg Iodine/ml Total 300x60= 18000mg 18000/300= 60ml Pediatric dose----1 ml per kg body wt Toxic levels are only just above the currently accepted doses of 2-4.4 ml contrast medium per kg bodyweight
  17. 17. IVP in Paediatrics  IV urography in neonates and infants the dose of contrast must be related to weight of patient and not its age  No dehydration ---CLEAR LIQUIDS should be consumed on the day of exam. Please note that Breast Milk is not considered a clear liquid and cannot be consumed for four (4) hours prior to the exam.  NO SOLIDS should be consumed for four hours prior to the exam  If child has a noted allergy to radiographic contrast, additional preparations  The injection should be slow, taking about three minutes
  18. 18. Congenital lesion  Related to metanephros: PUJ obstruction Ureterocoel Duplicated collecting system  Related to maturation: Renal agenesis Multicystic/ Dysplastic Medullary spong kidney  Related to migration: Renal ectopia Horse shoe kidney
  19. 19. Pelvi-uretro junction obstructionIt is caused by an overabundance of collagen tissue in the ureter, leading to thickening and stricture resulting in obstruction of the urinary tract. Early diagnosis is important to prevent hydronephrosis in severe, cases, can proceed to loss of renal cortex then poor renal function . Related to metanephros: PUJ obstruction Ureterocoel Duplicated collecting system
  20. 20. Ureterocoel A ureterocele is a congenital saccular dilatation of the terminal portion of the ureter. Classic appearance known as the "cobra head deformity“ resembles a snake's head bulging into the bladder, Best seen on IVP . Related to metanephros: PUJ obstruction Ureterocoel Duplicated collecting system
  21. 21. Duplicating collecting system Related to metanephros: PUJ obstruction Ureterocoel Duplicated collecting system
  22. 22. Renal agenesis When the ureteric bud fails to reach the metanephric blastema, there is no induction of nephron development, and the result is renal agenesis Ultrasound, CT, and radionuclide scan provide definitive diagnosis The contralateral kidney usually becomes hypertrophic and enlarged to compensate Related to maturation: Renal agenesis Multicystic/ Dysplastic Medullary spong kidney
  23. 23. Multicystic/Dysplastic kidney Multicystic dysplastic kidney (MCDK) occurs as a result of inadequate induction of maturation of the metanephric. Type 1. non-communicating cysts replace normal renal parenchyma. The kidney is not functional Type 2. hydronephrotic MCDK, is thought to occur later in gestation, representing a severe, in utero form of UPJ obstruction. Both forms present with an abdominal mass detected during infancy, and are associated with contralateral UPJ obstruction Related to maturation: Renal agenesis Multicystic/ Dysplastic Medullary spong kidney
  24. 24. Medullary sponge kidney/ renal tubular ectasia cystic dilatation of the collecting tubules in one or more renal pyramid. Urine stasis in the collecting tubules may lead to stone formation within the ectatic tubules Related to maturation: Renal agenesis Multicystic/ Dysplastic Medullary spong kidney
  25. 25. How kidneys migrate in abdomen Related to migration: Renal ectopia Horse shoe kidney  Ascent in the Abdomen  The metanephros begins its development in the upper sacral area during the 4th week of gestation, but with the rapid growth of the lumbar and sacral regions of the fetus, it migrates cephalad into the retroperitoneum of the upper abdomen. Horse shoe kidney Renal ectopia  Rotation Concommitant with the ascent into the abdomen, the kidneys undergo a medial rotation, bringing the ureteral pelvic junction to a medial position relative to the kidney vasculature
  26. 26. Horse shoe kidney on CT It is a result of contact between and fusion of the developing metanephros An isthmus develops between the two kidneys, consisting of a fibrotic band or functioning renal parenchyma
  27. 27. Renal ectopia Arrest or exaggeration of normal caudal-to-cranial ascent of the kidney, resulting in abnormal position. Pelvic kidney Premature arrest of cranial ascent of the kidney.
  28. 28. Fused and ectopic
  29. 29. Part 2---contents  Renal mass– solid or cyst  Renal parenchymal lesion---pyelonephritis/ GMN/ AIDS or analgesic nephropathy/
  30. 30. Renal mass solid or cystic  Renal cyst  Renal cell carcinoma  Angiomyolipoma are hamartomas containing fat, smooth muscle, and blood vessels  Oncocytoma Radiographic findings include a solid expansile mass with a pseudocapsule that is isoechoic or heterogeneous on ultrasound with heterogeneous enhancement on CT. Central stellate scars and a "spoke wheel" arteriographic pattern also suggests oncocytoma. Renal abscess CT findings include a well-defined focal renal mass with central necrosis  Lymphoma Radiographic findings include multiple lymphomatous masses (hypodense, hypoechoic), diffuse involvement of one or both kidneys, and associated adenopathy  Metastasis
  31. 31. BOSNIAK CLASSIFICATION OF RENAL CYSTS BY CT  I. Simple Cyst ----Nonoperative  II. Septated, minimal calcium described as “egg shell” thin, high- density cysts (> 20HU), non-enhancing –Nonoperative  III.Multiloculated, hemorrhagic, dense calcifications; nonenhancing solid component--Renal-sparing surgery  IV.Marginal irregularity, enhancing solid component-Radical Nephrectomy
  32. 32. Polycystic kidney disease  It is one of many pediatric cystic renal diseases.  On imaging, it usually presents on ultrasound with enlarged echogenic kidneys with multiple small cysts.  Liver-- coarse echotexture, biliary tract cystic changes, and portal hypertension 4 types----  perinatal type: most common  neonatal type: minimal hepatic fibrosis  infantile type: moderate periportal fibrosis  juvenile type: gross hepatic fibrosis with PH Autosomal recessive(ARPKD) less common than ADPKD
  33. 33. Autosomal dominant polycystic kidney disease (ADPKD/ a hereditary form of adult cystic renal disease.  The kineys are normal at birth.  At the age of 30 years, approximately 68% of patients will develop multiple cyst very well seen on ultrasound  It could be confirmed on CT or MRI
  34. 34. Autosomal Dominant Polycystic Kidney Disease (ADPKD)
  35. 35. Renal Cell carcinoma The classic triad of hematuria, flank pain, and a palpable abdominal On U/s generally hypoechoic ON CT Enhancing mass does not enhance as intensely as normal renal parenchyma due to distortion of parenchyma,
  36. 36. Renal parenchymal lesion  Small or large kidney  Renal artey stenosis most common cause of a unilateral small, smooth kidney  Reflux Nephropathy/ chronic atrophic pyelonephritis, reflux nephropathy is the result of parenchymal scarring caused by reflux of either sterile or infected urine leads to renal atrophy with an irregular contour.  Chronic Medical Renal Disease It presents as bilaterally small, smooth, and hyperechoic kidneys without focal scarring.  Analgesic Nephropathy Analgesic nephropathy is the result of chronic ingestion of large doses of NSAIDS, Findings include small, irregular kidneys; diffuse paillary necrosis; and medullary nephrocalcinosis (calcification of sloughed papilla)  AIDS nephritis  Acute GMN  Misc----Acute interstitial nephritis,  Von hippel lindaou, Tuberous sclerosis
  37. 37. Pyelonephritis  Pyelonephritis is a bacterial infection of the renal parenchyma and collecting system, a clinical diagnosis based on fever, flank pain, costovertebral angle tenderness, and urinary tract infection  Imaging is rarely required for diagnosis, but may be helpful if a more complicated infection, such as a renal abscess, is suspected.  CT findings include renal enlargement with wedge- shaped heterogeneous areas of poor enhancement, known as a “striated nephrogram”.
  38. 38. Acute pyelonephritis
  39. 39. Xantho glomerulo nephritis- Classic triad: usually unilateral enlarged kidney, nephrolithiasis, poor or absent renal function (limited or no uptake or excretion of contrast agent on CT or MRI)  XGP develops in patients with chronic urinary tract obstructions and infections that have usually been caused by nephrolithiasis  With chronic obstruction, lipid-laden histiocytes infiltrate the renal parenchyma, replacing the functional elements of the kidney.  XGP commonly spreads to surrounding tissues, including the collecting system, peri nephric fat, and through Gerota’s fascia to the psoas muscle, and may result in renal-cutaneous or renal-enteric fistulas
  40. 40. Xantho granulomatous Pyelonephritis (XGP)  XGP develops in patients with chronic urinary tract obstructions and infections that have usually been caused by nephrolithiasis, especially staghorn calculi  With chronic obstruction, lipid-laden histiocytes infiltrate the renal parenchyma, replacing the functional elements of the kidney  XGP commonly spreads to surrounding tissues, including the collecting system, perinephric fat, and through Gerota’s fascia to the psoas muscle, and may result in renal- cutaneous or renal-enteric fistulas. "bear paw" finding on CT scan
  41. 41. AIDS nephropathy—pentad of findings 1 .Proteinuria 2. Azotemia 3. normal-to-large echogenic kidneys on ultra sonography images 4.normal blood pressure 5. focal segmental glomerulo sclerosis on renal biopsy findings. There is both tubulointerstitial and glomerular components.
  42. 42. HIV associated nephropathy---- normal-to-large echogenic kidneys on ultra sonography images
  43. 43. Reflux nephropathy scarred kidney
  44. 44. Medical renal disease/ ESRD--- small echogenic kidney
  45. 45. Analgesic nephropathy--- Renal papillary necrosis is visible when excreted contrast material, e.g. at IVP, fills a necrotic cavity located centrally or peripherally in the papillae. --
  46. 46. Acute Glomerulonephritis Acute interstitial nephritis  Acute glomerulonephritis causes edema due to diffuse parenchymal inflammation leading to renal enlargement. Contrast-enhance CT is contraindicated in these patients  Ultrasound is the diagnostic modality of choice  Imaging studies are usually non-specific and may show only smooth bilateral renal enlargement during the acute phase of the disease The role of imaging in these patients is to exclude obstruction  Diagnosis usually requires a biopsy.  Kidney diseases that involve structures within the kidney yet outside the glomerulus are broadly referred to as tubulointerstitial  These diseases generally involve tubules and/or the interstitium of the kidney and spare the glomeruli.  By far the most common form of tubulointerstitial inflammation is immunologic from lupus or Goodpastures or from drug hypersensitivity .  Normal kidney size by ultrasound examination generally favors but does not prove a diagnosis of acute (thus potentially reversible) kidney disease..
  47. 47. Misc.-----Von Hippel-Lindau autosomal dominant disorder  It is characterized by a variety of benign and malignant neoplasms.  Common tumors include ----hemangioblastoma, clear cell renal cell carcinoma, pheochromocytoma serous cystadenoma and neuroendocrine tumors of the pancreas hepatic adenoma, endolymphatic sac tumors of the middle ear and papillary cystadenoma of the epididymis and broad ligament etc.  Findings highly suspicious of VHL include multiple simple renal cysts in combination with renal cell carcinoma and multiple pancreatic cysts
  48. 48. Misc.--- Tuberous sclerosis  Tuberous sclerosis is an autosomal recessive disorder caused by mutation of the tumor suppressor genes TSC1 and TSC2.  Tuberous sclerosis is a neurocutaneous disorder that affects many organ systems, including the brain, kidneys and skin.  Seizures in these patients are usually a result of CNS damage from cerebral hamartomas.  Diagnosis is clinical and requires two major criteria or one major and two minor criteria.  The classic triad of ------seizures, mental retardation, and facial angiofibromas (Vogt’s triad)  Radiographically, tuberous sclerosis is suspected when angiomyolipoma is found in patients with simple renal cyst
  49. 49. Part 3  Renal Trauma  Vesical lesion
  50. 50. Renal Trauma  Grade 1  Hematuria with normal imaging studies  Contusions  Nonexpanding subcapsular hematomas  Grade 2  Nonexpanding perinephric hematomas confined to the retroperitoneum  Superficial cortical lacerations less than 1 cm in depth without collecting system injury  Grade 3 – Renal lacerations greater than 1 cm in depth that do not involve the collecting system  Grade 4  Renal lacerations extending through the kidney into the collecting system  Injuries involving the main renal artery or vein with contained hemorrhage  Segmental infarctions without associated lacerations  Expanding subcapsular hematomas compressing the kidney  Grade 5  Shattered or devascularized kidney  Ureteropelvic avulsions  Complete laceration or thrombus of the main renal artery or vein
  51. 51. What do mean by renal contusion?  It is interstitial edema and hemorrhage as a result of a parenchymal bruise  Imaging shows an enlarged kidney with delayed pyelogram and diminished density of contrast in the calyces and ureter due to decreased function of the kidney
  52. 52. o m Extensive perirenal hemorrhage along the course of the renal artery, delayed and diminished nephrogram, and a rim nephrogram Right upper pole renal laceration dividing the renal parenchyma in two
  53. 53. Vesical lesion  Calcification/ calculus or schistosomiasis  Ca bladder: focal mural filling defect  Cystitis: Diffuse thickening of wall  Outpouching of vesical wall: Diverticum, cystocoel, herniation  Intravesical or interstitial air: vesical fistula , emphysematous cystitis  Vesical rupture  Urachal anomaly
  54. 54. Vesical wall calcification  Mnemonic---CREST  C: cystitis post radiation therapy/chemotherapy/ chronic infection  R: radiation  E: eosinophilic cystitis  S: schistosomiasis  T: tuberculosis
  55. 55. Urinary schistosomiasis  Bladder schistosomiasis, also known as bilharzia of the bladder, is an infection by the Schistosoma flukeworm and is a major health problem in developing parts of the world predisposing individuals to vesical squamous cell carcinoma  It contaminates fresh water in some areas of the world including Central Africa where this parasite is endemic  Clinically urinary schistosomiasis --- progressive frequency with hematuria & dysuria
  56. 56. Imaging findings-- mirror the pathologic course  In the acute phase, nodular bladder wall thickening is observed at urography/IVP  The chronic phase is characterized by a contracted, fibrotic, thick-walled bladder with calcifications  These calcifications are typically curvilinear and represent the large numbers of calcified eggs within the bladder wall  A mass may be secondary to inflammation or complicating carcinoma, typically SCC.
  57. 57. Schistosoma  There are five species of the blood fluke (trematode worm) Schistosoma species that cause disease in humans  Schistosoma haematobium  S. mansoni  S. japonicum  S. intercalatum  S. mekongi
  58. 58. Vesical mass/TCC frank hematuria needs cystscopy and biopsy
  59. 59. Cystitis  Cystitis is a clinical diagnosis; in most patients, imaging is not required.  The diagnosis is generally made by means of cystoscopy  However, some clinicians use ultrasonography to exclude secondary causes of cystitis, such as bladder outlet obstruction and bladder calculi
  60. 60. Cystitis—vesical wall thickening debris +
  61. 61. Out pouching vesical wall –mucosa herniates through vesical wall  It may be solitary or multiple in nature and can vary considerably in size.  Diverticula are often an incidental finding on imaging investigations on ultrasound, CT, MRI and IVU.  Complications due to stasis and low-grade infection including:  Intradiverticular -transitional cell carcinoma -bladder stones -bladder rupture
  62. 62. Causes  Primary (congenital or idiopathic)  Hutch diverticulum (in paraureteral region)  Secondary  bladder outlet obstruction  bladder neck stenosis  neurogenic bladder  posterior urethral valve  Enlarged prostate  ureterocele (large)  urethral stricture  Few congenital syndromes
  63. 63. Vesical diverticum
  64. 64. Vesical rupture– 5 types  Bladder contusion-- incomplete tear of the mucosa.  Subserosal/interstitial bladder rupture---rare  Intraperitoneal bladder rupture – trauma on distended bladder. Cystography -- intraperitoneal contrast material around bowel loops, between mesenteric folds and in the paracolic gutters.  Treatment is surgical repair.  Extraperitoneal bladder rupture--- common with pelvic fracture Cystography --- reveals a variable path of extra vasated contrast material. Treatment is with an indwelling Foley catheter  Combined bladder rupture
  65. 65. Radio graphic finding  Traditional investigation--- Fluoroscopic cystography  CT cystography----- is performed by instilling water-soluble contrast into the bladder through a Foleys catheter  It may be combined with standard CT to evaluate the upper tracts
  66. 66. Imaging vesical Rupture
  67. 67. Intravesical air  Pneumaturia is a word to describe air bubbles that pass in your urine  Pneumaturia alone isn't a diagnosis, but it can be a symptom of certain health conditions  causes--- urinary tract infections vesico- colic fistula
  68. 68. Urachal anomaly—due to incomplete involution of the urachus  Urachus connects the dome of the bladder to umbilical cord during fetal life located behind the lower anterior abdominal wall  By birth it is obliterated and becomes vestigial organ  If not obliterated it may persists in a number of configration
  69. 69. 4 types urachal anomaly Infection is the biggest problem due to stasis Treatment is not standardized.  Patent urachus– communication between bladder and umbilicus  Urachal cyst  Umbilical –urachal sinus—blind focal dilatation  Vesico urachal diverticulum
  70. 70.  Radiology male pelvis---- prostate and urethra  Radiology of adrenals separate topics
  71. 71. Have a nice day

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