BLOCK KIDNEY WEEK 5 / LECTURE 5&6 / dr.

Brian Lucas / RENAL SYSTEM IMAGING

MEDINA MARSYA (2018) – 01071180098

Renal System:

 Kidneys
 Ureters
 Urinary Bladder
 Urethra

KIDNEYS

 Retroperitoneal
 T12-L3
 Kanan lebih rendah dari kiri
 Arteri renalis diantara L1-L2
 Dari dalam ke luar: Cortex  Medula  Papilla  Minor Calyx (Pyramid, Cortex)  Major Calyx  Pelvis
Renal  Ureter
 Radiologi normal:

URETERS

 Medial dari kidney, Renal Hilum posterior renal vessel

 Inferomedial m. psoas major and transverse process
lumbar vertebra, lateral wall of pelvis, posterior aspect
of urinary bladder trigone
 Radiologi normal:

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BLADDER
 Pelvic floor, posterior pubic bone
 Fill – ascend greater pelvis as high as umbilicus
 Male: anterior rectum, superior prostate gland
 Female: anterior vagina, anteroinferior uterus
 Radiologi normal:

Radiology modalities:

 Conventional Radiography
 Intravenous Urography (IVU)
 US
 CT
 MRI
 Nuclear Imaging

Indikasi Renal System Imaging:

1. Hematuria
2. Renal colic
3. Recurrent UTI
4. Suspected urinary tract pathology

CONVENTIONAL RADIOGRAPHY

BENEFITS

 Murah

PLAIN X-RAY OF THE ABDOMEN; KIDNEY, URETER, BLADDER (KUB)

 Demonstrate the size and location ginjal  tp renal outline can be obscured by bowel content, lack of
perinephric fat, or a perinephric hematoma or abscess
 BILATERAL:
o unusually large  polycystic kidney disease, multiple myeloma, lymphoma, amyloid disease, or
hydronephrosis
o unusually small  end-stage glomerulonephritis, atau bilateral atrophic pyelonephritis
 UNILATERAL:
o enlargement  Kemungkinan renal tumor, cyst, or hydronephrosis
o kecil  congenital hypoplasia, atrophic pyelonephritis, atau ischemic kidney
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IMAGE FEATURES

 Projectional image
 Kontras gambar ditentukan oleh densitas jaringan
 Bagus untuk evaluasi batu ginjal radio-opaque
 Paling sederhana dan simpel
 KUB:

INTRAVENOUS UROGRAPHY / IVU / EXCRETORY UROGRAPHY

 X-ray polos + intravenous contrast

 Murah
 Bagus untuk Radio opaque stones
 Skrg lebih prefer CT dan MRI

IMAGE FEATURES

 Projectional image
 Functional dan anatomical information
 Kontras gambar ditentukan oleh density jaringan dan IV contrast
 Bagus untuk evaluasi: collecting system dan batu radio opaque
 Radiologi:

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TERMINOLOGY

1. UROGRAM: parenkim ginjal, calyx (minor&major), renal pelvis

2. PYELOGRAM: collecting system doang

RETROGRADE PYELOGRAPHY

 Indications: hematuria, contrast sensitivity, suboptimal IVU, needs ureteroscopy

 Pre-Op: get sterile urine culture
 IV Sedation
INFO
 Scout, injection catheter placed in UO, inject 50% contrast under real-time fluoro, drainage
film at 5-10 minutes
 Backflow: contrast extravasation into surrounding tissues due to high injection pressure
 Non-visualization of ureteral segment on IVU and CTU
 If there is still clinical concern for evaluating the collecting system after IVU/CTU, a
INDICATION
retrograde pyelogram may be able to get better image of ureter segment
 Better characterization of ureteral or pelvicalyceal abnormalities seen on IVU or CTU

RADIOLOGY
NORMAL

3. CYSTOGRAPHY: Bladder
Norma
4. URETHROGRAPHY: Urethra

RETROGRADE URETHROGRAM (RUG)

 Evaluate anterior and posterior urethral strictures, trauma

 8-16F foley in fossa navicularis, fill balloon with 1-2 mL and inject 30-50% contrast while
INFO
filming obliquely
 Some resistance at membranous urethra and sphincter

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RADIOLOGY

5. CYSTOURETHROGRAPHY: Bladder dan urethra

VOIDING CYSTOURETHROGRAM (VCUG)

 Functional and anatomic evaluation of bladder

 Typically, untuk children with recurrent UTIs
 Diagnosis: reflux, urethral valves, ureterocele, dysfunctional voiding, urethral
strictures, bladder/urethral diverticula
 Scout
 Pediatric: 5 or 8F feeding tube, fill bladder with contrast (Age +2 x 30)
 Adult: standard catheter
 Film during filling: bladder pathology, early reflux
INFO  Films during void: reflux, urethral abnormality
 Oblique: evaluate grade 1 reflux, males
 Post-void film
 The bladder is filled with contrast using an infant feeding tube under aseptic
precautions; a Foley catheter can be used for older children
 Intermittent screening of the patient on fluoroscopy, while distending the bladder with
contrast, is necessary to check for a ureterocoele or VUR
 After the bladder is filled to its capacity (bervariasi), the patient is now asked to void

 All males with recurrent UTIs or abnormality on USG if first UTI
 Females <3 years of age with UTI pertama
 Females <5 years of age with febrile UTIs
INDICATION  Older females dgn pyelonephritis or recurrent UTIs
 Suspected obstruction (e.g. bilateral hydronephrosis)
 Suspected bladder trauma or rupture
 Stress incontinence (urine)
PROJECTIONS
(should be
1. AP with full bladder  demonstration of the presence/absence of VUR
acquired
2. Both obliques  to demonstrate vesicoureteric junctions
keeping within
3. Post void film  to check for ureterocoele
the ALARA
principle)

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 VCUG

ADVANTAGES

 Identifying the anatomical relationship of the UT System to the calcification

 Demonstrate the presence/absence dari UTO (urinary tract obstruction)
 Melihat UT system
 Bisa evaluasi contralateral kidney

DISADVANTAGES

 May miss small stones

 The passage of stones causing edema/swelling at the UVJ mimicking the appearance of a retained stone
 Risks associated with IV contrast: anaphylaxis, pruritus, and renal failure
 Exposure to ionizing radiation
 Quality of study may be limited by inadequate bowel preparation, bowel ileus, swallowed air, and
technician variability
 Inconvenience of a long filming sequence
 Kalo IVP (-) untuk obstruksi calculus  may fail to adequately diagnose other extraurinary causes of
acute flank pain

PREPARATION

 Ur/Cr <2
 Bowel Preparations:
1. Eliminate fecal material
2. Kurangin jumlah gas di bowel
 Improves degree of opacification of contrast
 Patient now kept NPO to decrease chance of vomiting dan producing slight dehydration
 Peralatan Steril
1. Skin test: Spuit 1cc
2. Persiapan obat emergency: Spuit 3cc
3. Bahan kontras: spuit 50cc
4. Wing needle
5. Jarum no.18
6. Kapas alkohol
 Peralatan Unsteril:
1. Kontras Media: e.g. iopamiro, ultravist
2. Stuwing  untuk pembendung vena

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 3. Gunting
4. Plester
5. Obat emergency: e.g dhypenhydramine
 Contrast
o Inject non-ionic contrast as bolus selama 30-60s
1. Hand-inject: ±100cc
2. Usually 18g needle in antecubital vein with syringe connected to tubing
o Reaksi akibat contrast: dose-related atau idiosyncratic
1. Alergi, CV changes, shock
2. Tx: antihistamines, beta agonist, epinephrine

3. Renal toxicity
 Average patient 1%
 Direct toxicity ke renal tubules, ischemia, altered precipitation of uric acid
 Prevention: well hydrated, LOCM, small load

BNO  dilakuin dalam posisi supine

Function:

1. Untuk evaluasi technique

2. Mencari calcifications
3. Abnormal soft tissue
4. Udara dalam UT
5. Bony abnormalities
6. Menentukan if a contraindication to abdominal compression exists

Radiologi normal:

Films

 Main Aims
1. Assess bladder emptying
2. Demonstrate rerun of dilated upper tracts with relief of bladder pressure
3. Aid diagnosis of VJ calculi
4. Diagnosis of bladder tumours
5. Demonstrate urethral diverticulum
6. Residual volume of urine

 Additional views
o Oblique views
o Good for questionable ureteral lesions

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 o For differentiating extrinsic and intrinsic renal and ureteral masses
o Visualization of posterolateral aspect of bladder
 Delayed views
o 1 hour to 48 hours  pd kasus obstruksi
o Lebih prefer langsung CT Scan
 Normal Bladder: pre&post void

 Transitional Cell Carcinoma

 Process of filming:
1. Immediate Films
o AP of the renal areas
o Exposed 10-14s after injection (approximate arm to kidney time)
o Aim: to show the nephrogram (i.e. renal parenchyma opacified by contrast medium in renal tubules)

2. 5-min films
o AP of renal areas
o Aim: to determine If excretion is symmetrical
and is invaluable for assessing the need to
modify the technique, e.g. a further injection of
CM if there has been poor initial opacification

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3. Compression Band dipasang around the patient’s abdomen and the balloon is positioned midway between
the ASIS i.e. precisely over the ureters as they cross the pelvic brim.
o Aim: to produce better pelvicalyceal distention
o Kontraindikasi:
a.
b. Setelah recent abdominal surgery
c. Setelah renal trauma
d. Ada large abdominal mass/aortic aneurysm
e. Udah menunjukkan distended calyces pada 5min film
4. Ureteral Compression Films
o Value
a. Normal peristaltis may leave portions of ureters empty of contrast
b. With compression, ureters are composed against pelvis and are temporarily obstructed
c. As a result, the proximal ureters and intrarenal collecting system are optimally distended
o Proper compression
a. Ureters are compressed against pelvis
b. Place belt and pneumatic balloons at upper edge anterior superior iliac spine
c. Paddles should nearly meet at the midline
o Radiologi normal

5. 15-min films
o Supine full length AP
o Biasanya ada adequate distention of the pelvicalyceal systems with opaque urine by this time
o Compression dilepas kalo satisfactory demonstration of the pelvicalyceal system has been achieved

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6. Release film
o saat full bladder
o coned view of bladder area
o Untuk menunjukkan bladder
o If this film is satisfactory, the patient is asked to empty the bladder
o Radiologi normal:

7. After Micturition Film

o Full length abdominal film/coned view of the bladder with the tube angled 15° caudad and centred
5cm above the symphysis pubis based on earlier findings
o Radiologi normal:

8. Radiologi normal overall process

9. C o m p r e s s

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US

CHARACTERISTICS

 Use high frequency sound wave

 Contrast between tissue is determined by sound reflection

IMAGE FEATURES

 Operator dependant
 Anatomical
 Good resolution
 Untuk stone, hydronephrosis, focal lesion

DIAGNOSTIC VALUE

 Show the renal parenchymal changes

 Detection of UT Calculi
 UT obstruction
 Renal and Bladder Masses
 Differentiates cystic from solid masses
 Congenital anomalies
 Doppler assessment of the renal vessels

RADIOLOGY

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CT SCAN

CHARACTERISTICS

 Anatomical
 More precise
 Mahal
 +/- contrast
 Useful untuk trauma, stone, tumour, infection
 Justified as first-line test untuk pasien dengan macroscopic haematuria, high risk of urothelial cancer.
 CTU (CT Urography) Untuk evaluasi renal masses, UT calculi, genitourinary trauma, and renal infection
 CTU: useful untuk surveillance of patients with a history of urothelial cancers, patients with obstructive
uropathy (e.g. Hydronephrosis, hydroureter of unknown Etiology), or any time a comprehensive
evaluation of the UT is warranted

IMAGE FEATURES

 Cross sectional image

 Kontras gambar ditentukan oleh tissue density and +/- contrast
 Better evaluation of soft tissue

DIAGNOSTIC VALUE

 Detection of UT Calculi
 UT obstruction
 Renal and bladder masses
 Differentiates cystic from solid masses
 Congenital anomalies
 CT angiography

RADIOLOGY

 CTU-
Reconstructed Image

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  CTA

MRI
CHARACTERISTICS
 Better evaluation of soft tissue
 Expensive
 Anatomical
 Useful untuk soft tissue pathology; tumor, infection
 No iodinated contrast
 Soft tissue resolution lebih baik dibanding dengan CT
 Kontraindikasi: pacer, aneurysm clips, FB, prosthetis
 Alignment of protons in response to external magnet-radiofrequency applied causes difference in their energy
 T1: Fluid dark, fat bright
 T2: Fluid bright, fat dark

IMAGE FEATURES

 Cross-sectional
 Kontras gambar ditentukan oleh tissue properties
 Excellent untuk soft tissue evaluation

MRU

 Untuk pasien yang gabisa receive iodinated contrast material or for whom exposure to ionizing radiation is
particularly undesirable
 Most commonly indicated in children and pregnant patients with dilated collecting system

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  Indications:
1. Preoperative anatomic imaging for the assessment of vascular anatomy
2. Evaluation of duplex systems
3. Distinction between pelvicalyceal dilatation and cystic disease
 Radiology:

NUCLEAR MEDICINE

CHARACTERISTICS

 Utilizes a gamma camera and radioactive isotopes

 Functional test
 Less expensive
 Useful untuk obstruction and split function

IMAGE FEATURES

 Projectional image
 Kontras gambar dengan tissue uptake and metabolism

INDICATIONS

 Renal perfusion and function

 UTO (Furosemide renal scan)
 Renovascular HTN (Captopril renal scan)
 Infection (Renal morphology scan)
 Pre-surgical quantitation (Nephrectomy)
 Renal Transplantation
 Congenital anomalies/masses (renal morphology scan)

NUCLEAR SCINTIGRAPHY

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  Physiologic and anatomic info
 TC-99m (t ½ = 6 jam)
 MAG 3/Mercaptoacetyltriglycine): cleared by tubular secretion, no glomerular infiltration  evaluate renal
function and renal plasma flow
 DTPA / Diethylenetriamine Penta-acetic: Glomerular filtration  evaluate obstruction and renal function
 DMSA / Dimercaptosuccinic Acid: cleared by filtration and secretion  renal cortical image
 Renal radiotracers:

PATIENT PREPARATION

 Must be well hydrated

o Give 5-10mL/Kg water (2-4 cups) 30-60 min pre-injection
o Can measure U-specific gravity
 Void before injection
 Void @end of study
 Tracer: MAG3, DTPA
o Dose: 2-5 mCi adult, minimum 0.5 mCi peds
 Patient position: Supine (motion, depth issues)
o Include bladder, heart
 Collimator: LEAP
 Image over injection site

DTPA NORMAL

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RELATIVE/SPLIT FUNCTION ROI’S

 Normal : 50/50 – 56/44

 Borderline : 57/43 – 59/41
 Abnormal : >60/40

RENAL ARTERY OCCLUSION

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RT RENAL INFARCT

PATIENTS WITH HEMATURIA

ACR APPROPRIATENESS
CRITERIA SCALE FOR
HEMATURIA

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PATIENTS WITH RENAL COLIC

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