THE URINARY TRACT

Methods of examination
Plain film of the abdomen – patient in supine position, kidneys,
ureteral and bladder areas. Assessment of the size, shape and position of
the kidneys, the presence of calcium, psoas muscle abnormalities.
IVU – i.v. injection of radioopaque contrast medium. Serial films
are obtained over 15 to 25 minutes as the contrast agent is excreted by
the kidneys for visualization of the renal collecting system, ureters and
bladder (first film obtained after 1 minute and a second film after 5
minutes).Compression – film. Patient preparation – bowel cleansing to
remove gas and fecal matter from the colon.Contraindications to
injection of i.v. contrast medium :
- hypersensitivity to the contrast agent
- renal and hepatic disease
- asthma
- a serum creatinine level higher than 3mg/100ml
- multiple myeloma
- history of severe allergy
 US
CT
MRI
Retrograde pyelography – cystoscopy and catheterization of the
ureters are necessary.
Antegrade pyelography – a needle is placed percutaneously into the
renal pelvis from a posterolateral approach and either fluoroscopic or
ultrasonic guidance is used. Conventional percutaneous nephrostomy,
brush biopsy, stent placement, stone dissolution or extraction, pressure
flow study, dilatation of stenosis can be performed using the access
gained to the collecting system.
Renal angiography – first global aortography followed by selective
renal artery catheterization. Used for renal angioplasty/stenting and renal
embolization.
Cystography – after voiding a urethral catheter is inserted and the
bladder is filled with contrast medium. Indications: bladder rupture,
tumors, diverticula.
Renal scintigraphy – 99Tc and 131I. Indication – renal function.
 Anomalies in number

Renal agenesis – single kidney. Method of choice –

angiography.

Supernumerary kidney – the usual finding is that the

anomalous kidney is small and the other kidney on the same
side is often smaller than the normal kidney on the opposite
side.Demonstration of the presence of a separate pelvis,
ureter and blood supply is necessary to make the
diagnosis.
 Anomalies in size and form
Hypoplasia – usually associated with hyperplasia on the
other. The hypoplastic kidney functions normally.It must be
differentiated from the acquired atrophic kidney which is
small and contracted because of vascular or inflammatory
disease.In congenital hypoplasia the collecting system is small
and there is a normal relation between the amount of
parenchyma and the size of calices and renal pelvis.
Hyperplasia – is associated with agenesis or hypoplasia on
the opposite side (more properly termed compensatory
hypertrophy). Conditions that usually cause bilateral renal
enlargement: acute glomerulonephritis, lymphoma, leukemia
in children, systemic lupus erithematosus, polycystic disease,
bilateral renal vein thrombosis, amyloidosis, sarcoidosis,
lobular glomerulonephritis, total lipodystrophy.
 Fusion anomalies

Horseshoe kidney – the lower poles of the kidney are

joined by a band of soft tissue, the isthmus. The long axis of
the kidney is reversed so that the lower pole is nearer the
midline than the upper.There is also an associated rotation
anomaly. The calyces are directed backward or
posteromedially.The ureters tend to be streched over the
isthmus and partial obstruction is not unusual.This leads to
dilatation of the pelvis and calyces.
Do CT !!!

Crossed ectopy – fusion of the kidneys on the same side;

the lower one is ectopic and its ureter crosses the midline to
enter the bladder normally on the opposite side. Do CT &US
 Anomalies in position

Malrotation – results from incomplete or excessive

rotation and urographic study indicates the degree of
anomaly.

Ectopy – pelvis, thorax. Do CT !!!

Nephroptosis – downward displacement and more

mobility of the kidney than usual.
Anomalies of the renal pelvis and ureter
Ureteropelvic junction anomalies – usually bilateral but not
always simmetrical.
Duplication of the pelvis and ureter
Retrocaval ureter – is limited to the right side.The ureter
passes to the left behind the IVC.
Ureterocele – intravesical dilatation of the ureter immediately
proximal to its orifice in the bladder.It varies in size from a
small dilatation to one that is moderately large and resembles a
cobra head in shape.When the ureterocele is not filled with
contrast it appears as a radiolucent mass within the opacified
bladder in the region of the ureteral orifice.If it is filled, the
lesion is outlined by a radiolucent wall that stands out in
contrast to the filled bladder and to the filled, dilated, distal
ureter.
Ureteral diverticula
OBSTRUCTIVE UROPATHY
Nonobstructive hydronephrosis – diabetes, infections, appendicitis,
peritonitis
Congenital hydronephrosis – obstruction at the UPJ, vesicoureteral
reflux, congenital ureterocele, urethral valves, congenital strictures.
Acquired hydronephrosis – tumors, calculi, strictures, radiation
therapy, surgery, prostatic enlargement, pregnancy in the third
trimester,abdominal aortic aneurysm.
Imaging findings
- US method of first choice to evaluate patients with suspected
hydronephrosis (mild, moderate, severe).
- CT + i.v.contrast medium – useful to assess the cause of obstruction.
- Urography – early : flattening of the normal concavity of the calyx and
a blunting of the sharp angle produced by the papilla + decrease in the
rate of contrast material accumulating in the collecting system. Calyces
then gradually enlarge with progressive destruction of parenchyma. A
prolonged and increasingly dense nephrogram is characteristic of acute
renal obstruction. In severe cases do percutaneous nephrostomy.
CALCULI
Incidence – 5% of population; 20% at autopsy.Recurrence of
stone disease – 50%.
Predisposing conditions – calyceal diverticuli, renal tubular
acidosis, hypercalcemia, hypercalciuria.
The radiographic density of a calculus depends on its calcium
contents:
- Calcium calculi (opaque) 75% - calcium oxalate and
phosphate.
- Struvite calculi (opaque) 15% - magnesium ammonium
phosphate:”infection stones”; struvite is usually mixed with
calcium phosphate to create “triple phosphate” calculi.
- Cystine calculi (less opaque) – cystinuria.
- Nonopaque calculi – uric acid, xanthine, mucoprotein matrix
calculi in poorly functioning, infected urinary tract.
Radiographic features
Calculus (determine size, number, location)
Radioopaque calculus are best detected on KUB or helical CT
Radiolucent calculi are best detected by IVU
Renal calculi can be detected by US – hyperechoic focus,
posterior shadowing
IVU
Delayed and persistent nephrogram due to ureteral obstruction
Ureter distal to calculus is narrowed (edema, inflammation),
may create false impression of stricture
Ureter proximal to calculus is persistently minimally dilated
“steinstrasse” – several calculi are bunched up along the ureter
CT
CT detects most calculi regardless of calcium content
Helical CT is very useful to detect small calculi
Location – 3 narrow sites:
UPJ, at crossing of ureter with iliac vessels, UVJ
Complications:
- Forniceal rupture (pyelosinus backflow)
- Chronic calculous pyelonephritis
- XGP
Treatment options:
-Small renal calculi ( 2,5cm) – ESWL
(extracorporeal shock wave lithotripsy)
- Large renal calculi ( 2,5 cm) – percutaneous removal
- Upper ureteral calculi – ESWL
- Lower ureteral calculi – ureteroscopy
Differential diagnosis
- Gallstones
- Calcification of costal cartilage
- Calcified mesenteric nodes
- Calcifications in cysts and tumors
- Vascular calcification
Staghorn calculus
URINARY TRACT INFECTION
Acute pyelonephritis
Acute bacterial infection of the kidney and urinary tract – Proteus,
Klebsiella, E.Coli
Role of imaging studies:
- Define underlying pathology – obstruction, reflux, calculus
- Rule out complications – abscess, emphisematous pyelonephritis
Types
Focal type – lobar nephronia
Diffuse type – more severe and extensive
Radiographic features
- Renal enlargement (edema)
- Loss of corticomedullary differentiation (edema)
- IVU – delay of contrast excretion, narrowing of collecting system,
striated nephrogram,
- Areas of decreased perfusion by CT
Chronic pyelonephritis
Criteria for diagnosis:
- The disease is centered in the medulla, with scarring
eventually affecting the entire thickness of renal substance
- There is an irregular surface depression over the involved
area
- The involved papilla is retracted because of scarring with
secondary dilatation of its calyx
- The dilated calyx has a smooth margin but variable shape
- Renal tissue adjacent to the involved area is normal or
hypertrophied with a sharp definition between normal and
abnormal
- Distribution is unifocal or multifocal involving one or both
kidneys
- There is an decrease in size of the involved kidney
RENAL ABSCESS
Usually caused by gram negative bacteria. Underlying disease
– calculi, obstruction, diabetes, AIDS.
 
Radiographic features
Well-delineated focal renal lesion
Central necrosis
Thickened abscess wall with contrast enhancement
Perinephric inflammatory involvement

Complications: retroperitoneal spread of abscess, renocolic

fistula
TUBERCULOSIS
GU tract is the second most common site of TB involvement after the
lung.The disease is typically due to hematogeneous spread.
Clinical – history of pulmonary TB, pyuria, hematuria, dysuria
Radiographic features
Distribution – unilateral involvement is more common – 70%
Size – early- kidneys are enlarged,
late- the kidneys are small, autonephrectomy
Parenchyma
Parenchymal calcifications –curvilinear, mottled, amorphous
Papillary necrosis
Tuberculoma
Parenchymal scarring
Collecting system
Infundibular stenosis
Amputated calyx
Corkscrew ureter – multiple stenosis
“pipestem” ureter refers to a narrow, rigid aperistaltic segment
CYSTIC DISEASE
Symple cysts
Probably arise from obstructed tubules or ducts.They do not
communicate with the collecting system.
Clinical – most commonly asymptomatic; rare hematuria,
HTN
 
Radiographic features
IVU – lucent defect, cortical bulge, round indentation on
collecting system
US – anechoic, sharply marginated, smooth walls, very thin
septation may be seen
CT – smooth cyst wall, sharp demarcation from surrounding
renal parenchyma, water density that is homogeneous, no
enhancement.
Complicated cysts – Bosniak classification:
- category 1 lesions – benign simple cyst
- category 2 lesions – these minimally complicated cysts are
benign but have certain radiologic findings of concern.This
category includes septated cysts, minimally calcified cysts,
high-density cysts
- category 3 lesions – complicated cystic lesions that exibit
some radiologic patterns also seen in malignancy. This
category includes multiloculated cystic nephroma, complex
septated cyst, heavily calcified cyst and cystic renal cell
carcinoma.Surgery is usually performed
- category 4 lesions – clearly malignant lesions with large
cystic component. Irregular margins, solid vascular elements
ADULT POLYCYSTIC KIDNEY DISEASE
Cystic dilatation of collecting tubules as well as nephrons.
Autosomal dominant trait.
Clinical – slowly progressive renal failure.
Treatment – dialysis, transplant.
Associated findings – hepatic cysts, intracranial aneurysm,
cysts in pancreas and spleen.
Radiographic features
-kidneys are enlarged and contain innumerable cysts, creating
a boselated surface.
-They do not communicate with the collecting system
- calcification of cyst wall is common
- pressure deformities of calyces and infundibula
- “swiss-cheese” nephrogram
BENIGN TUMORS
Angiomyolipoma
Hamartomas containing fat, smooth muscle and blood vessels.
Treatment – small lesions are not treated; large and symptomatic lesions
are resected or embolized
Complication – tumors may spontaneously bleed because of their
vascular elements
CT method of choice
Adenoma
Low grade adenocarcinoma with no metastatic potential.
Usually detected at autopsy
Oncocitoma
These tumors arise from oncocytes of the proximal tubule.
Radiographic features – central stellate scar (CT) , well-defined sharp
borders
Juxtaglomerular tumor (reninoma)
Secretion of renin causes HTN, hypernatremia, hypokalemia.
Tumors appear as small hypovascular masses
RENAL CELL CARCINOMA
Synonyms – renal adenocarcinoma, hypernephroma, clear cell
carcinoma
Clinical – hematuria, flank pain, palpable mass, weight loss,
paraneoplastic syndrome: hypertension (renin), erythrocytosis
(erythropoietin), hypercalcemia (PTH), gynecomastia
(gonadotropin), Cushing syndrome (ACTH)
Risk factors – tobacco, phenacetin long term use, Von Hippel-
Lindau disease, chronic dialysis, family history
Radiographic features
IVU – renal mass with renal contour deformity,
calyceal displacement and destruction
US – hyperechoic, nonhomogeneous, irregular borders
CT – hypodense mass, enhancement, calcifications, necrosis,
irregular borders
Angiography – hypervascular, caliber irregularities of tumor
vessels, prominent AV shunting, venous lakes, preoperative
embolization
Staging
Stage I – tumor confined to kidney
Stage II – extrarenal but confined to Gerota’s fascia
Stage III A – venous invasion; B- lymph node metastases ; C – both
Stage IV A – direct extension into adjacent organs ; B – metastases
(lung, liver, bone, adrenal, contralateral kidney)
Therapy – radical nephrectomy, chemotherapy, radiotherapy
Renal pelvis tumors – transitional cell carcinoma
Tumors are often multifocal – ureter, bladder.
Radiographic features –
irregular filling defect, wall thickening, polypoid mass.
Staging
Stage I – mucosal lamina propria involved
Stage II – into but not beyond muscular layer
Stage III – invasion of adjacent fat / renal parenchyma
Stage IV - metastases