Rad Fergu Final

8/13/2019 Rad Fergu Final

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Genitourinary Radiology

Prepared for the UBC Undergraduate Medical Program2007

Contributors

Stephen Ho, Savvas Nicolaou, John Aldrich, Leo Mok


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Main Index

Imaging techniquesPatient preparation

Normal anatomyPathological conditions


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Contents

Patient preparation

Normal anatomy

4.4.2 Renal colic4.4.3 Urosepsis4.4.4 Renal mass4.4.5 Acute/chronic renalfailure4.4.6 Trauma

Renal and ureteric calculiHydronephrosisRenal cyst versus renal carcinomaAdditional Pathological Conditions

Microscopic hematuriaTransitional cell carcinoma

Pathologicalconditions

Imaging techniquesChoosing the most appropriate testPlain radiographs and tomograms

Retrograde pyelogramIntravenous pyelogram (IVP)Ultrasound (US)Computed tomography (CT)

Nuclear medicine renogramMagnetic resonance imaging (MRI)Angiography


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1.Imaging Techniques

Choosing the most appropriate testPlain radiographs and tomograms

Retrograde pyelogramIntravenous pyelogram (IVP)Ultrasound (US)Computed tomography (CT)

Nuclear medicine renogramMagnetic resonance imaging (MRI)Angiography


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Choosing the most appropriate test

For imaging GU functionIVP

Nuclear renogram

For imaging GU anatomyPlain radiographsIVP, retrograde pyelogramUS, CT, MRI


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Plain Radiographs and Tomography

Indications

Screening forurinary calculi

Diffuse abdominal painEssential part of IVP


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Plain Radiographs andTomography


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Retrograde Pyelogram

Performed byurologist in OR

Requires generalanaestheticExcellent detailof urinarycollecting system


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Intravenous Pyelogram (IVP)

Demonstrates renal, ureteral and bladderanatomy

Gross estimate of functionIonizing radiationRequires IV contrastPatient prep


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IVP

Consists of a KUB and a series of post-contrastinjection film

1) Pre-contrast scout (KUB) film2) Nephrogram phase

- typically at 1 minute post-contrast injection

3) Subsequent post-contrast injection films


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Preliminary film 30 second film


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5 minute filmRenal tomogram

Ureteral compression

applied


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Film after ureteral compression released


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Ultrasound

Excellent renal and bladder anatomyCan assess blood flow

Useful in helping differentiate between solid andcystic massesCan use TRUS to evaluate the prostate or guide

biopsiesPoor ureteral anatomy

No functional information


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Ultrasound


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Ultrasound


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Computed Tomography (CT)

Used selectively for specific indicationsExcellent anatomic detail

Ionizing radiationUsually requires IV contrast


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Computed Tomography (CT)

CT anatomy


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Magnetic Resonance (MRI)

Used selectively for specific indicationsExcellent anatomic detail of kidneysSafely performed in renal failure

No ionizing radiation


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Magnetic Resonance (MRI)


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Nuclear Medicine

Excellent physiologic imaging toolAccurately measures renal function

Poor anatomic detailIonizing radiation


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Nuclear Medicine

Two types of renal scans:

1) renogram: used to quantitate renal function2) morphological study: examines renal anatomy


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Angiography

GU hemorrhageRenal artery stenosis

Partial nephrectomySignificant risk of complications

Very expensive


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Angiography


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Patient Preparation

Renal CTAPatient to drink 750 cc water or juice 1 hour prior to CT

Pelvic ultrasound Patient must have a full bladder for this examFinish drinking 32 oz. (approximately 4 glasses) of water2 hours prior Do not void after drinking


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Patient Preparation

MRIHair must be dryDo not wear any jewelryOwn clothing free of metals (zipper, hooks, buttons)

No fasting or special diets needed Patients with colds or coughs will be rescheduled (due to

motion with sniffing or clearing)


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Patient Preparation

IVP- clear fluids the day before

- NPO after midnight the day before- cathartics the evening before


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Normal Anatomy

Identify:Kidney

Renal pelvis

Renal calyx

Ureter

Bladder


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Normal Anatomy

KidneyBladder

AortaRenal arteries

Identify:


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Renal Calculi


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Renal Calculus - US


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Hydronephrosis


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Approach to Renal Masses

Most renal masses are simple cystsUse US to characterize the mass

simple cyst : STOPsolid mass or atypical cyst: CT

US and CT characterize > 90% of masses > 1.5 cmBiopsy is rarely warranted


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Renal Mass

Simple cyst on ultrasound


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Renal Masses

Initial investigation should be USCysts: uniformly hypoechoic, good throughtransmission, imperceptible wallTumours: solid, contour deforming


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Renal Mass

Left renal mass on IVP


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Renal Cysts

- US will determine if the lesionis cystic or solid

- 2 Types of Renal Cysts:

1) Simple: spherical, echo-freefluid collection within a thinsurrounding wall and will showgood sound wave transmission

2) Complicated: will show the presence of echos within the cyst,will have a thick wall, and/or showcalcification in the wall


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Renal Carcinoma

- if US indicates that the mass issolid, CT with IV contrast can

characterize the tumour in greater detail delineate extent, showthe degree of vascularity,

presence/absence of necrotic

centre, presence/absence of localinvasion of adjacent structures


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Additional PathologicalConditions

Microscopic hematuriaTransitional cell carcinoma

Renal colicUrosepsisRenal massAcute/chronic renal failureTrauma


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Microscopic Hematuria

Abnormality in 88% of patients9% have GU tract malignancy

Etiologies: infections, stones, tumoursRule out infection with clinical/lab dataUse imaging to evaluate for structuralabnormality (stone, mass)


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Acceptable imaging strategies1) KUB to identify stones

- Renal US to identify mass- Cystoscopy and Retrograde if KUB and US normal

2) IVP- Renal US and Cystoscopy if IVP normal


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Microscopic HematuriaUltrasound of a right renal calculus


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Microscopic HematuriaBladder Calculi


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Transitional Cell Carcinoma

Most common malignancy of ureter and bladder


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IVP and retrograde pyelogram TCC proximal left ureter


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IVP and retrograde pyelogram TCC proximal left ureter


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IVP and pelvic CT large TCC of bladder obstructing right ureter


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Small TCC of bladder in patient with hematuria


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Bladder TCC in two patients


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Renal Colic

Questions to ask:Are urinary stones present?

If so, what is the level and size?

Is obstructions present?If so, what is the level and severity

Is urgent intervention required?Factors include: urosepsis, solitary kidney, severe pain

Treatment: percutaneous nephrostomy or ureteric stent


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Renal Colic

Preliminary film in patient with right renal colic


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Renal Colic

10 minutes

Delayed functionon right side

25 hours

Persistent nephrogram

29 hours

Dilated ureter to stone


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Renal Colic

Radiopaque stone distal ureter


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Renal Colic

Radiolucent uric acid stones


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Renal Stones

Management dictated by size and location ofstonesESWL monotherapyUreteroscopyPercutaneous debulkig and ESWLSurgery is rarely necessary


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Urosepsis

Establish a clinical diagnosis: pyelonephritis, cystitis, prostatitisUrosepsis and an obstructed ureter is aurologic emergency!

Renal US performed to rule out:

Renal obstructionRenal or perirenal abscess


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Urosepsis

Left pyonephrosis Right UPJ stone causinghydronephrosis


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Urosepsis

Ultrasound showing a right pyonephrosis and obstructing UPJ stone


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Urosepsis

Percutaneous nephrostomyfor decompression 2 weeks post ESWL


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Renal Mass

Most renal masses are simple cystsUse US to characterize the mass

simple cyst : STOP

solid mass or atypical cyst: CT

US and CT characterize > 90% of masses > 1.5 cmBiopsy is rarely warranted


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Renal Mass

Left renal mass on IVP Simple cyst on ultrasound


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Renal Mass

Distortion of left pelicalyceal system in IVP


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Renal Mass

Solid left renal mass in a patient with micro hematuria


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Renal MassRenal Angiomyolipoma

Benign harmartomatous tumour comprised offat, smooth muscle and vesselsUsually asymptomaticOccasionally present with hemorrhage whenlarge or multiple

Fat detected in 96% by CT


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Renal MassRenal Adenocarcinoma

90% of all renal malignancies15-30% metastatic at diagnosisHematogenous and lymphatic spread 10% have venous invasion (renal vein or IVC)Treatment:

Radical nephrectomyPartial nephrectomy


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Renal MassRenal Adenocarcinoma

Appropriate imaging workup:Chest X-ray: pulmonary metastasesCT abdomen: local invasion, lymphadenopathy,venous extensionMRI abdomen: renal failure, contrast allergy


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Acute and Chronic Renal Failure

Clinical catergoriesPrerenal (dehydration, shock, cardiac failure)Renal (parenchyma, diabetes, GN, drugs, renovascular)Postrenal (obstruction)

IV contrast contraindicated if creatinine > 200 mmol/d

Use ultrasound to assess:Renal size

Parenchymal thickness

Ultrasound guided renal biopsy to establish diagnosis


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Acute and Chronic Renal Failure

Hydronephrosis post-renal Atropic, echogenic kidney

Medical renal disease


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GU TraumaPenetrating trauma (gunshot, stab)

UnstableSurgery or angiography

StableCT


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GU Trauma


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GU TraumaBlunt Trauma (MVA, fall, crush)

Unstable: surgery or angiographyStable: CT abdomen + cystogram

Gross hematuriaMicro hematuria + shock Major visceral injury: no imaging necessary if

Micro hematuria, no shock No other visceral injuries


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GU Trauma

Grade 5 injury: thrombosed renal artery


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GU Trauma

Grade 4 injury: deep lacerations with perirenal hemorrhage


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GU Trauma

Extraperitoneal bladder rupture Intraperitoneal bladder rupture


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GU Trauma

Normal retrogradeurethrogram

Traumatic rupture of bulbous urethra

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