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URORADIOLOGY Ayşegül SARSILMAZ M.D. Radiology

URORADIOLOGY Ayşegül SARSILMAZ M.D. Radiology. Radiological Modalities. Ultrasound Intravenous Pyelography Computed Tomography Magnetic Resonance Imaging Radionuclide Scanning. Ultrasound CT  Anatomical info. MRI Radionuclide  Functional info.

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URORADIOLOGY Ayşegül SARSILMAZ M.D. Radiology

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  1. URORADIOLOGY Ayşegül SARSILMAZ M.D. Radiology

  2. Radiological Modalities • Ultrasound • Intravenous Pyelography • Computed Tomography • Magnetic Resonance Imaging • Radionuclide Scanning

  3. Ultrasound CT  Anatomical info. MRI Radionuclide  Functional info. IVP  Anatomical + Fnx.

  4. ULTRASOUND • First line investigation !!! • Provides anatomical information without ionizing radiation • No need for intravenous contrast !!!

  5. INDICATIONS (USG) • İnvestigate patients with symptoms thought to arise from UT • Size of the kidneys • Presence of hydronephrosis • Renal tumors, cysts, abcesses • Assess bladder and prostate

  6. Normal Findings • Kidneys; smooth in outline • Central echogenic region (renal sinus) • Renal cortex (hypoechoic) • Pyramids (triangular hypoechoic areas) • Size : 90-120 mm • Urinary Bladder : examined in distended state, imperceptible walls, anechoic lumen

  7. Intravenous Pyelography • Largely replaced by US • 50-100 ml of contrast is injected intravenously • Carried via blood to the kidneys, passes through the glomerular filtrate  collecting systems • Main indications: • Detailed demonstration of PCS and ureters • Acute ureteric colic • Investigation of renal calculi • Investigation of hematuria

  8. First step: Plain film • Look at renal contour • Identify all calcifications !!! • Urinary calculi (kidney,ureter,bladder) • Nephrocalcinosis • Prostatic calcification

  9. Kidneys: position , length , contours • Calices: should be symmetrical, cup-shaped. • If dilated  club-shaped (due to obstruction or destruction of papilla) • Renal pelvis and ureters: normal pelvis is funnel-shaped, ureters are seen in only part of their length due to peristaltism. • Bladder:centrally located, smooth outline, should be empty after micturition

  10. Computed Tomography • Indications: • To characterize renal masses and stage tumors • To diagnose or exclude renal trauma • To demonstrate stones • To assess acute ureteric colic • To delineate renal vascular anatomy

  11. Normal Findings • Renal sinus ; low attenuation in the center • There should not be any calcification • Ureters are seen as dots in cross section lying on the psoas muscles • Bladder has a smooth outline, thin wall, anechoic urine. • Axial images may be reformatted in the coronal and sagittal planes

  12. MRI • Used in selected circumstances • (renal artery stenosis, IVCal extension of renal tumors)

  13. Voiding Cystourethrogram • Bladder is filledwithcontrastmediumthrough a catheterandfilmsaretakenduringvoiding • Observedfluoroscopicallytoidentifyreflux of contrastmediumfrombladdertoupper UT. • Risk of urinarytractinfection, chronicpyelonephritisandrenalscarring is increased in VUR.

  14. Grading of VUR Grade 1 reflux of urine only into the ureter Grade 2 reflux into the pelvis and calices, no dilatation Grade 3 mild to moderate dilatation of the ureters and renal pelvis Grade 4 moderate dilatation and tortuosity of the ureters,pelvis,calices Grade 5 gross dilatation and tortuosity of the ureters,pelvis and calices

  15. UPPER URINARY TRACT DISORDERS • Urinary Calculi • Urinary Tract Obstruction • Renal Parenchymal Masses • Urothelial Tumors • Acute Pyelonephritis, Perinephric abscess • Chronic Pyelonephritis • Congenital Anomalies

  16. LOWER URINARY TRACT DISORDERS • Bladder Tumors • Bladder Diverticula • Prostatic Enlargement

  17. Urinary Calculi • Most calculi are calcified and can be seen as radiodense on plain x-ray. • Only pure uric acid and xanthine stones are radiolucent on plain radiography, and they can be identified at CT or US. • US ; hyperechoic with posterior acoustic shadowing • CT ; hyperdense

  18. UPPER URINARY TRACT DISORDERS • Urinary Calculi • Urinary Tract Obstruction • Renal Parenchymal Masses • Urothelial Tumors • Acute Pyelonephritis, Perinephric abscess • Chronic Pyelonephritis • Congenital Anomalies

  19. Urinary Tract Obstruction • Themainfeature is dilatation of thepelvicalicealsystemandureters • Maincauses : • Calculi • Bloodclot • Sloughedpapilla • Tumors • US, IVP and CT

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

  21. IVP • Plain films may be helpful to demonstrate the calculus • Delayed films are essential • Filling of the pelvicaliceal system with contrast medium is greatly delayed.

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

  23. UPPER URINARY TRACT DISORDERS • Urinary Calculi • Urinary Tract Obstruction • Renal Parenchymal Masses • Urothelial Tumors • Acute Pyelonephritis, Perinephric abscess • Chronic Pyelonephritis • Congenital Anomalies

  24. Renal Parencymal Masses • Causes: cyst, benign tumor (angiomyolipoma), renal cell carcinoma, metastases, abscess • US • usually renal masses are first detected by US. • Cystic versus Solid • Simple cyst: common in elderly, solitary or multiple, unilocular or septated. Acoustic enhancement.

  25. Angiomyolipoma: small echogenic masses.

  26. Renal Cell Carcinoma • RCCs account for 86% of all primary renal parenchymal tumors. • On US; solid tumors • May be iso, hypo or hyperechoic. • When a tumor is demonstrated, extension into the renal vein and inferior vena cava should be assessed.

  27. CT • Useful for diagnosis and staging of renal tumors • Shows local direct spread, enlargement of lymph nodes, liver or other organ metastases, renal vein and IVC involvement.

  28. UPPER URINARY TRACT DISORDERS • Urinary Calculi • Urinary Tract Obstruction • Renal Parenchymal Masses • Urothelial Tumors • Acute Pyelonephritis, Perinephric abscess • Chronic Pyelonephritis • Congenital Anomalies

  29. Urothelial tumors are seen as filling defects in the renal pelvis and ureters • Filling defects in the collecting system: calculi, blood clot, tumor • They may obstruct the ureter and cause hyrdonephrosis.

  30. Congenital Anomalies • Bifid Collecting System • Ectopic Kidney • Horseshoe kidney • Renal Agenesis

  31. Bifid Collecting System • Most frequent congenital variation • Unilateral or bilateral • Bifid pelvis ................ureteric duplication

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