CHAPTER 9 The Kidney and Urinary Tract 317

Causes of Hydronephrosis

Genitourinary Obstruction Comments Genitourinary Obstruction Comments

Renal/ureteral stone
Transitional cell carcinoma
Sloughed papilla
Blood clot
Posterior urethral valves
Ureterocele
Ureteropelvic junction
obstruction
Ureteral stricture (prior
infection, surgery,
radiation)
Neurogenic bladder
Extrinsic Obstruction
Retrocaval ureter
Prostatic hypertrophy
Tumor (fibroid, ovarian
carcinoma, lymphoma)
Lymphadenopathy
Retroperitoneal fibrosis
Look for stone in common
sites of obstruction:
ureterovesical junction
and ureteropelvic junction
Hematuria
Hematuria
Bilateral, pediatric diagnosis
May be orthotopic or
heterotopic
If heterotopic, look for renal
duplication abnormality
Extrarenal pelvis may be
dilated out of proportion
to calices
History aids in diagnosis
Check for postvoid residual
May need CT for diagnosis
Enlarged prostate impinges
on bladder
Abnormal mass seen in
pelvis
Abnormal mass seen in
pelvis
Mass encasing the aorta
CT may be needed for
diagnosis
Aneurysm Should be obvious on
Doppler assessment of
vessels
Endometriosis Mass typically seen in
pelvis
Pregnancy Ureter dilated to pelvic brim
Nonobstructive
Vesicoureteral reflux Cortical scarring, typically in
upper poles
Congenital megacalices May be unilateral or
bilateral
If associated with
congenital megaureter,
both dilated ureter and
calices will be present
May need contrast-
enhanced CT for
diagnosis
Prior obstruction Prior severe dilatation may
not return to normal
Infection Signs and symptoms of
infection
High flow states (diabetes Typically mild dilatation
insipidus, psychogenic
polydipsia)
Distended bladder Returns to normal after
bladder emptying

PITFALLS IN ASSESSMENT with unilateralhypoplasia are asymptomatic; the condition is

OF OBSTRUCTION
Although obstruction typically causes dilatation, early in the
process the renal collecting system may not dilate. In cases of
renal failure, a poorly functioning kidney may not make sufficient
urine to demonstrate dilatation. In addition, in cases of severe
obstruction, pelvocaliceal rupture may lead to decompression
of the collecting system with a perinephric hematoma/urinoma.
Hydronephrosis (a condition in which dilated calices communicate
with central collecting system) should be distinguished from
multiple parapelvic cysts (which do not communicate).
CONGENITAL ANOMALIES
Anomalies Related to Renal Growth
Hypoplasia
Renal hypoplasia is a renal parenchymal anomaly in which there
are too few nephrons. Renal function depends on the mass of
the kidney. True hypoplasia is a rare anomaly. Many patients
typically an incidental finding. Patients with bilateralhypoplasia
often have renal insufficiency. Hypoplasia is believed to result
from the ureteral bud making contact with the most caudal
portion of the metanephrogenic blastema. This can occur with
delayed development of the ureteric bud or from delayed contact
of the bud with the cranially migrating blastema. Hypoplasia is
established when fewer but otherwise histologically normal renal
lobules are identified.14 At ultrasound, the kidney is small but
otherwise appears normal.
Fetal Lobation
Fetal lobation is usually present until 4 or 5 years of age; however,
persistent lobation is seen in 51% of adult kidneys.15 There is
infolding of the cortex without loss of cortical parenchyma. At
ultrasound, sharp clefts are shown overlying the columns of
Bertin.16
Compensatory Hypertrophy
Compensatory hypertrophy may be diffuse or focal. It occurs
when existing healthy nephrons enlarge to allow healthy renal
parenchyma to perform more work. The diffuse form is seen
318 PART II Abdominal and Pelvic Sonography
with contralateral nephrectomy, renalagenesis,renalhypoplasia,
renal atrophy, and renal dysplasia. Diffuse compensatory
hypertrophy is suggested at ultrasound when an enlarged but
otherwise normal-appearing kidney is identified. The focal form
is seen when residual islands of normal tissue enlarge in an
otherwise diseased kidney; focal compensatory hypertrophy may
be particularly prominent in the setting of reflux nephropathy.
Large areas of nodular but normal renal tissue identified between
scars may mimic a solid renal mass.5
Anomalies Related to Ascent of Kidney
Ectopia
Failure of the kidney to ascend during embryologic development
results in a pelvic kidney; prevalence is 1 in 724 pediatric
autopsies.16 These kidneys are often small and abnormally rotated.
Fifty percent of pelvic kidneys have decreased function.16 The
ureters are often short; poor drainage and collecting system
dilatation predispose pelvic kidneys to infection and stone forma-
tion. The blood supply is often complex; multiple arteries may
be derived from regional arteries (typically, internal iliac or
common iliac). If the kidney ascends too high, it may pass through
the foramen of Bochdalek and become a true thoracickidney;
this is usually of no clinical significance. A search for a pelvic
kidney should be performed if the kidney is not identified within
renal fossae (Fig. 9.9). If the kidney has ascended too high,
ultrasound is helpful to determine if the diaphragm is intact.
Crossed Renal Ectopia
In crossed renal ectopia, both kidneys are found on the same
side. In 85% to 90% of cases, the ectopic kidney will be fused
to the other kidney (crossed-fusedectopia). The upper pole of
the ectopic kidney is usually fused to the lower pole of the other
kidney, although fusion may occur anywhere. The incidence is
1 in 1000 to 1 in 1500 at autopsy.15 Fusion of metanephrogenic
blastema does not allow proper rotation or ascent; thus both
kidneys are more caudally located, although the ureterovesical
FIG. 9.9 Pelvic Kidney. Transverse sonogram demonstrates a left
pelvic kidney posterior to the uterus (*).
junctions (UVJs) are located normally. At sonography, both
kidneys are on the same side and are typically fused (Fig. 9.10).
In patients with renal colic, knowing that the UVJs are in the
normal location is particularly important, since bilateral ureters
need to be assessed.
Horseshoe Kidney
The incidence of horseshoe kidneys in the general population
is 0.01% to 0.25%. Horseshoe kidneys occur when metaneph-
rogenic blastema fuse prior to ascent; fusion is usually at the
lower poles (95%). Typically, the isthmus is composed of function-
ing renal tissue, although rarely it is made up of fibrous tissue.
The horseshoe kidney sits anterior to the abdominal great vessels
and derives its blood supply from the aorta and other regional
vessels, such as inferior mesenteric, common iliac, internal iliac,
and external iliac arteries. Abnormal rotation of renal pelves
often results in ureteropelvicjunction(UPJ) obstruction; the
horseshoe kidney is thus predisposed to infection and stone
formation. Additional associated anomalies include vesicoureteral
reflux,collectingsystemduplication,renaldysplasia,retrocaval
ureter, supernumerary kidney, anorectal malformation,
esophageal atresia, rectovaginal fistula, omphalocele, and
cardiovascular and skeletal abnormalities.
At sonography, horseshoe kidneys are usually lower than
normal and the lower poles project medially. Transverse imaging
of the retroperitoneum will demonstrate the renal isthmus crossing
the midline anterior to abdominal great vessels (Fig. 9.11).
Hydronephrosis (pyelocaliectasis) and collecting system calculi
may be evident.
Anomalies Related to Ureteral Bud
Renal Agenesis
Renal agenesis may be unilateral or bilateral. Bilateral renal
agenesis is a rare anomaly that is incompatible with life. The
prevalence rate of bilateral agenesis at autopsies is 0.04%. The
condition has a 3 : 1 male predominance.15 Unilateral renal
FIG. 9.10 Cross-Fused Ectopia. Sagittal sonogram demonstrates
two kidneys fused to each other.
 CHAPTER 9
H orseshoe kidney
RK LK
A B
FIG. 9.11 Horseshoe Kidney. (A) Transverse sonogram shows the isthmus crossing anterior to the retroperitoneal great vessels, with the
renal parenchyma of each limb of the horseshoe draping over the spine. (B) Confirmatory contrast-enhanced CT examination. LK, Left kidney; RK,
right kidney.
agenesis is usually an incidental finding; the contralateral kidney
of these patients may be quite large secondary to compensatory
hypertrophy. Renal agenesis occurs when there is (1) absence
of the metanephrogenic blastema, (2) absence of ureteral bud
development, or (3) absence of interaction and penetration of
the ureteral bud with the metanephrogenic blastema. Renal
agenesis is associated with genital tract anomalies, which are
often cystic pelvic masses in both men and women. Other
associated anomalies include skeletal abnormalities, anorectal
malformations,and cryptorchidism.
At ultrasound, although the kidney is absent, a normal adrenal
gland is usually found. The adrenal gland will be absent in 8%
to 17% of patients with renal agenesis.16 It may be difficult to
differentiate between renal agenesis and a small, hypoplastic or
dysplastic kidney. With all these conditions, the contralateral
kidney will be enlarged as a result of compensatory hypertrophy.
Usually, the colon falls into the empty renal bed. Care should
be taken not to confuse a loop of gut with a normal kidney.
Supernumerary Kidney
Supernumerary kidney is an exceedingly rare anomaly. The
supernumerary kidney is usually smaller than normal and can
be found above, below, in front of, or behind the normal kidney.
The supernumerary kidney often has only a few calices and a
single infundibulum. The formation of a supernumerary kidney
is likely caused by the same mechanism that gives rise to a duplex
collecting system.15 Two ureteric buds reach the metanephrogenic
blastema, which then divides, or alternatively, there are initially
two blastema. On sonography, an extra kidney will be found.
Duplex Collecting System and Ureterocele
Duplex collecting system is the most common congenital anomaly
of the urinary tract, with an incidence of 0.5% to 10% of live
births.15 The degree of duplication is variable. Duplication is
complete when there are two separate collecting systems and
two separate ureters, each with their own ureteral orifice. Duplica-
tion is incomplete when the ureters join and enter the bladder
through a single ureteral orifice. Ureteropelvic duplication arises
The Kidney and Urinary Tract 319
when two ureteral buds form and join with the metanephrogenic
blastema or when there is division of a single ureteral bud early
in embryogenesis. Normally during embryologic development,
the ureteral orifice migrates superiorly and laterally to become
part of the bladder trigone. With complete duplication, the ureter
from the lower pole of the kidney migrates to assume its normal
location, whereas the ureter draining the superior pole of the
kidney migrates abnormally to a more medial and inferior ureteral
orifice. Patients have an increased incidence of UPJ obstruction
and uterus didelphys.16
In complete duplication, the ureter draining the lower pole
has a more perpendicular course through the bladder wall, making
it more prone to reflux. The ectopic ureter from the upper pole
is prone to obstruction, reflux, or both (Fig. 9.12). Obstruction
can result in cystic dilatation of the intramural portion of the
ureter, giving rise to a ureterocele. Ureterocelesmay be unilateral
or bilateral and may occur in normal, duplicated, or ectopic
ureters. Ureteroceles may result in ureteral obstruction and give
rise to recurrent or persistent UTIs. If large, they may block the
contralateral ureteral orifice and the urethral orifice at the bladder
neck. Treatment of these symptomatic ureteroceles is surgical.
However, most ureteroceles are transient, incidental, and clinically
insignificant.
At ultrasound, a duplex collecting system is seen as two central
echogenic renal sinuses with intervening, bridging renal paren-
chyma. Unfortunately, this sign is insensitive and is only seen in
17% of duplex kidneys.17 Hydronephrosis of the upper-pole moiety
and visualization of two distinct collecting systems and ureters
are diagnostic. The bladder should always be carefully evaluated
for the presence of a ureterocele. A ureterocele will appear as a
round, cystlike structure within the bladder (Fig. 9.13). Occasion-
ally, it may be large enough to occupy the entire bladder and will
cause obstruction of the bladder neck. In female patients, trans-
vaginal sonography can be helpful to identify small ureteroceles18
(Fig. 9.14). These ureteroceles may be transient. Madeb et al.19
demonstrated that transvaginal sonography with color Doppler
and spectral analysis can provide additional information about
flow dynamics, eliminating the need for invasive procedures.
320 PART II Abdominal and Pelvic Sonography

A B
FIG. 9.12 Duplex Collecting System. (A) Sagittal sonogram shows an upper-pole cystic mass. Note collecting system dilatation and cortical
thinning. (B) Delayed intravenous urogram shows duplicated left collecting system and dilated upper-pole moiety.

A B

FIG. 9.13 Duplex Collecting System. (A) Sagittal

sonogram shows dilatation of the lower-pole moiety, likely
related to reflux. (B) Sagittal sonogram shows central
parenchyma separating the upper-pole and lower-pole moi-
eties. There is moderate dilatation of both moieties. (C)
Sagittal sonogram of the bladder and distal ureter of the
patient in B. Note dilatation of the ureter from the upper-pole
C
moiety and a large ureterocele.
 CHAPTER 9
Ureteropelvic Junction Obstruction
UPJ obstruction is a common anomaly with a 2 : 1 male pre-
dominance. The left kidney is affected twice as frequently as the
right kidney. UPJ obstruction is bilateral in 10% to 30% of cases.20
Most adult patients present with chronic, vague, back or flank
pain. Symptomatic patients and those with complications, includ-
ing superimposed infection, stones, or impaired renal function,
should be treated. Patients have an increased incidence of contra-
lateral multicystic dysplastic kidney and renal agenesis. Most
idiopathic UPJ obstructions are thought to be functional rather
than anatomic.20 Histologic evaluation of affected specimens has
demonstrated excessive collagen between muscle bundles, deficient
or absent muscle, and excessive longitudinal muscle.20 Occasionally,
intrinsic valves, true luminal stenosis, and aberrant arteries are
the cause of obstruction. At ultrasound, hydronephrosis is present
FIG. 9.14 Small Bilateral Ureteroceles. Transverse transvaginal
sonogram demonstrates two small cystic structures related to the bladder
wall. With the probe in the vagina, the bladder trigone and the ureteric
orifices are shown in the near field of the transducer.
A B
FIG. 9.15 Ureteropelvic Junction Obstruction. (A) Sagittal and (B) transverse sonograms demonstrate marked ballooning of the renal pelvis
with associated proximal caliectasis.
The Kidney and Urinary Tract 321
to the level of the UPJ (Fig. 9.15). Marked ballooning of the
renal pelvis is often shown, and if long-standing, there will be
associated renal parenchymal atrophy. The caliber of the ureter,
on the other hand, is normal. Careful evaluation of the contralateral
kidney should be performed to exclude associated anomalies.
Congenital Megacalices
Congenital megacalices refer to typically unilateral, nonobstructive
enlargement of the calices. It is nonprogressive; overlying
parenchyma and renal function are maintained. Infection and
stone formation are increased because of caliceal enlargement.
The exact pathogenesis is speculative; the most common associa-
tion is with primary megaureter.21 At ultrasound, numerous
enlarged clubbed calices are shown. Papillary impressions are
absent, and cortical thickness is maintained.
Congenital Megaureter
Megaureter (congenital megaureter, megaloureter) results in
functional ureteric obstruction. The most distal segment of ureter
is aperistaltic: focal ureteral lack of peristalsis results in a wide
spectrum of findings, from insignificant distal ureterectasis to
progressive hydronephrosis/hydroureter. As with UPJ obstruc-
tions, men are affected more often, and the left ureter is typically
involved.20 Bilateral involvement has been demonstrated in 8%
to 50% of patients. The classic finding at ultrasound is fusiform
dilatationof the distal third of the ureter (Fig. 9.16). Depending
on the severity, associated pyelocaliectasis may or may not be
present. Calculi may form just proximal to the adynamic segment.
Anomalies Related to Vascular
Development
Aberrant Vessels
As it ascends during embryologic development, the kidney derives
its blood supply from successively higher levels of the aorta.
322 PART II Abdominal and Pelvic Sonography
A B
FIG. 9.16 Congenital Megaureter. (A) Sagittal sonogram shows marked dilatation of the distal ureter up to the ureterovesical junction.
(B) Sagittal sonogram shows moderate midregion ureterectasis.
Aberrant renal arteries will be present if the vascular supply
from the lower levels of the aorta persists. Aberrant vessels can
compress the ureter anywhere along its course. Color Doppler
ultrasound may be useful to identify obstructing vessels crossing
at the UPJ.
Retrocaval Ureter
Retrocaval ureter is a rare but well-recognized congenital anomaly
with a 3 : 1 male predominance. Most patients present with pain
in the second to fourth decade of life. Normally, the infrarenal
inferior vena cava (IVC) develops from the supracardinalvein;
if it develops from the subcardinal vein, the ureter will pass
posterior to the IVC. The ureter then passes medially and
anteriorly between the aorta and IVC to cross the right iliac
vessels. It then enters the pelvis and bladder in a normal manner.
Sonography shows collecting system and proximal ureteral dilata-
tion. In easy-to-scan patients the compressed retrocaval ureter
may be identified.
Anomalies Related to Bladder Development
Bladder Agenesis
Bladder agenesis is a rare anomaly. Most infants with bladder
agenesis are stillborn; virtually all surviving infants are female.22
Many associated anomalies are often present. At ultrasound, the
bladder is absent.
Bladder Duplication
Bladder duplication is divided into three types, as follows16:
Type1: A complete or incomplete peritoneal fold separates the
two bladders.
Type 2: An internal septum divides the bladder. The septum
may be complete or incomplete and may be oriented in a
sagittal or coronal plane. There may be multiple septa.
Type3: A transverse band of muscle divides the bladder into
two unequal cavities.
Bladder Exstrophy
Bladder exstrophy occurs in 1 in 30,000 live births, with a 2 : 1
male predominance.16 Failure in development of the mesoderm
below the umbilicus leads to absence of the lower abdominal
and anterior bladder wall. There is a high incidence of associated
musculoskeletal, gastrointestinal, and genital tract anomalies.
These patients have an increased (200-fold) incidence of bladder
carcinoma (adenocarcinoma in 90%).16
Urachal Anomalies
Normally, the urachus closes in the last half of fetal life.16 The
four types of congenital urachal anomalies, in order of frequency,
are as follows16,23,24 (Fig. 9.17):
1. Patent urachus (50%)
2. Urachal cyst (30%)
3. Urachal sinus (15%)
4. Urachal diverticulum (5%)
Urachal anomalies have a 2 : 1 predominance in males. A
patenturachusis usually associated with urethral obstruction
and serves as a protective mechanism to allow normal fetal
development. A urachalcystforms if the urachus closes at the
umbilical and bladder ends but remains patent in between. The
cyst is usually situated in the lower third of the urachus. There
is an increased incidence of adenocarcinoma. At ultrasound, a
midline cyst with or without internal echoes is seen superior to
the bladder. A urachalsinusforms when the urachus closes at
the bladder end but remains patent at the umbilicus. A urachal
diverticulumforms if the urachus closes at the umbilical end
but remains patent at the bladder. Urachal diverticula are usually
incidentally found. There is an increased incidence of carcinoma
and stone formation.
 CHAPTER 9
A B
C D
FIG. 9.17 Congenital Urachal Anomalies. (A) Patent urachus extends
from the bladder to the umbilicus. (B) Urachal sinus. (C) Urachal
diverticulum. (D) Urachal cyst.
A B
FIG. 9.18 Urethral Diverticulum in Young Woman With Palpable Vaginal Mass. (A) Sagittal and (B) transverse translabial sonograms show
a complex cystic mass adjacent to the anterior urethra.
The Kidney and Urinary Tract 323
Anomalies Related to Urethral
Development: Diverticula
The majority of urethral diverticula are acquired secondary
to injury or infection, although congenital diverticula occur
rarely. Most urethral diverticula in women form as a result of
infection of the periurethral glands; some may be related to
childbirth. Most diverticula are found in the midurethra and
are bilateral. Often, a fluctuant anterior vaginal mass is felt.
Stones may develop because of urinary stasis. Transvaginal
or translabial scanning may demonstrate a simple or complex
cystic structure communicating with the urethra through a thin
neck (Fig. 9.18).
GENITOURINARY INFECTIONS
Pyelonephritis
Acute Pyelonephritis
Acute pyelonephritis is a tubulointerstitial inflammation of the
kidney. Two routes may lead to inflammation: ascending infection
(85%; e.g., Escherichia coli) and hematogenous seeding (15%;
e.g., Staphylococcus aureus). Women age 15 to 35 years are most
often affected25; 2% of pregnant women will develop acute
pyelonephritis.26 Most adults present with flank pain and fever
and can be diagnosed clinically with the aid of laboratory studies
(bacteriuria, pyuria, and leukocytosis). With appropriate antibiot-
ics, both clinical and laboratory findings show rapid improvement.
Imaging is necessary only when symptoms and laboratory
abnormalities persist: imaging is useful to identify potential causes
of insufficiently treated infection, including renal and perirenal
abscesses, calculi, and urinary obstruction. The Society of
Uroradiology proposed using acute pyelonephritisto describe
acutely infected kidneys, eliminating the need for terms such as
bacterial nephritis, lobar nephronia, renal cellulitis, lobar nephritis,
renal phlegmon, and renal carbuncle.27