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AIIMS-MAMC-PGI's Comprehensive Textbook of Diagnostic Radiology
AIIMS-MAMC-PGI's
Comprehensive Textbook of
DIAGNOSTIC RADIOLOGY
AIIMS-MAMC-PGI's
Comprehensive Textbook of
DIAGNOSTIC RADIOLOGY
Third Edition
Volumes 1–4
• Genitourinary Imaging
• Advances in Imaging Technology
• Paediatric Imaging
• Gastrointestinal and Hepatobiliary
Imaging
• Chest and Cardiovascular Imaging
• Musculoskeletal and Breast Imaging
• Neuroradiology Including Head and
Neck Imaging
Editors
Arun Kumar Gupta MD FAMS

Professor and Head
Department of Radiodiagnosis
All India Institute of Medical Sciences
New Delhi, India
Anju Garg MD
Director Professor and Head
Maulana Azad Medical College
New Delhi, India
Manavjit Singh Sandhu MD FICR CCST (UK)

Professor and Head
Postgraduate Institute of
Medical Education and Research
Chandigarh, India
Jaypee Brothers Medical Publishers (P) Ltd
Headquarter
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari Road, Daryaganj
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© 2021, Jaypee Brothers Medical Publishers
The views and opinions expressed in this book are solely those of the original contributor(s)/author(s)
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AIIMS-MAMC-PGI’s Comprehensive Textbook of Diagnostic Radiology, Third Edition (Volumes 1 to

4) / Arun Kumar Gupta, Anju Garg, Manavjit Singh Sandhu
First Edition: 2016

Second Edition: 2019
Third Edition: 2021
ISBN: 978-93-90595-55-6
Printed at:
ASSOCIATE
EDITORS
VOLUME 1
Section 1: Genitourinary Imaging

Gaurav Shanker Pradhan
Alpana Manchanda MD Sapna Singh MD DNB MNAMS
DMRD DNB
Director Professor Professor
Director Professor
Department of Radiodiagnosis Department of Radiodiagnosis
Maulana Azad Medical College Maulana Azad Medical College
New Delhi, India New Delhi, India
New Delhi, India
Section 2: Advances in Imaging Technology
Sanjay Sharma MD DNB Atin Kumar MD DNB MNAMS Shivanand Gamanagatti MD
MNAMS FRCR FICR FICR MNAMS FICR
Professor Professor Professor
Department of Radiodiagnosis Department of Radiodiagnosis Department of Radiodiagnosis
(RP Center division) (Trauma Centre Division) (Trauma Centre Division)
All India Institute of Medical All India Institute of Medical All India Institute of Medical
Sciences New Delhi, India Sciences New Delhi, India Sciences New Delhi, India
VOLUME 2
Section 3: Paediatric Imaging

Ashu Seith Bhalla MD Manisha Jana MD DNB Devasenathipathy Priyanka Naranje MD
MAMS FICR FRCR Kandasamy MD DNB DNB MNAMS
Professor Additional Professor FRCR Associate Professor
Department of Department of Additional Professor Department of
Radiodiagnosis Radiodiagnosis Department of Radiodiagnosis
Radiodiagnosis
All India Institute of All India Institute of All India Institute of
All India Institute of
Medical Sciences New Medical Sciences New Medical Sciences New
Medical Sciences New
Delhi, India Delhi, India Delhi, India
Delhi, India
Section 4: Gastrointestinal and Hepatobiliary Imaging
Deep Narayan
Raju Sharma MD MAMS
Srivastava MD MBA
FICR
FAMS FICR
Professor
Professor
Department of
Department of
Radiodiagnosis
Radiodiagnosis
Delhi, India
Delhi, India
VOLUME 3
Section 5: Chest and Cardiovascular Imaging

Sanjiv Sharma MD Rashmi Dixit MD
Professor and Head Director Professor
Department of Cardiovascular Radiology and Endovascular Department of Radiodiagnosis
Interventions CN Centre All India Institute of Medical Sciences Maulana Azad Medical College
New Delhi, India New Delhi, India
Section 6: Musculoskeletal and Breast Imaging
Anindita Sinha MD MAMS
Mahesh Prakash MD MAMS FIACM FICR
Additional Professor
Professor
Postgraduate Institute of Medical
Postgraduate Institute of Medical Education and Research
Education and Research
Chandigarh, India
Chandigarh, India
VOLUME 4
Section 7: Neuroradiology Including Head and Neck Imaging

Shailesh B Gaikwad
Ajay Garg MD
Paramjeet Singh MD MD FNAMS CCST
Vivek Gupta MD DM Professor
FICR Professor and Head
Former Professor Department of
Professor Department of
Department of Neuroimaging and
Department of Neuroimaging and
Radiodiagnosis Interventional
Radiodiagnosis Interventional
Postgraduate Institute of Neuroradiology (CN
Postgraduate Institute of Neuroradiology (CN
Medical Education and Centre)
Medical Education and Centre)
Research Chandigarh, All India Institute of
Research Chandigarh, All India Institute of
India Medical Sciences New
India Medical Sciences New
Delhi, India
Delhi, India
CONTRIBUTORS
Ajay Garg MD (Radiodiagnosis) Eur Dip in Neuroradiology (EDiNR) Eur Dip in Pediatric
Neuroradiology (EDiPNR)
Professor, Department of Neuroimaging and Interventional Neuroradiology
CN Centre
New Delhi, India
Ajay Gulati MD MAMS

Postgraduate Institute of Medical Education and Research, Chandigarh, India
Ajay Kumar MD
Professor
Akshay Kumar Saxena MD DNB FICR

Professor
Alpana Manchanda MD
Director Professor
New Delhi, India
Anil Kumar Pandey MSc PhD

Associate Professor (Medical Physics)
Department of Nuclear Medicine and PET
New Delhi, India
Anindita Sinha MD MAMS
Chandigarh, India
Anjali Prakash DMRD DNB MNAMS

Director Professor
New Delhi, India
Anju Garg MD
Director Professor and Head
New Delhi, India
Ankur Goyal MD DNB MNAMS

Associate Professor
New Delhi, India
Anmol Bhatia MD FPGI (Paediatric Radiology)

Assistant Professor
Department of Radiodiagnosis and Imaging
Chandigarh, India
Anuj Prabhakar DNB DM (Neuroradiology)

Assistant Professor
Chandigarh, India
Anupam Lal MD
Professor
Chandigarh, India
Arun Kumar Gupta MD FAMS

Professor and Head
New Delhi, India
Ashu Seith Bhalla MD MAMS FICR
Professor
New Delhi, India
Atin Kumar MD DNB MNAMS FICR

Professor
(Trauma Center Division)
New Delhi, India
Chandan J Das MD DNB MAMS FICR FRCP

New Delhi, India
Chandrashekhara SH MD DNB MNAMS

Dr BRA Institute—Rotary Cancer Hospital
New Delhi, India
Chirag Kamal Ahuja MD DM (Neuroradiology)

Associate Professor
Chandigarh, India
Deep Narayan Srivastava MD MBA FAMS FICR

Professor
New Delhi, India
Devasenathipathy Kandasamy MD DNB FRCR

New Delhi, India
Ekta Dhamija MD
Associate Professor
Dr BRA Institute—Rotary Cancer Hospital
New Delhi, India
Gaurav Shanker Pradhan DMRD DNB

Director Professor
New Delhi, India
Gita Devi MD DNB

Assistant Professor
Chandigarh, India
Gurpreet Singh Gulati MD

Former Professor
Department of Cardiac Radiology
Cardio-Thoracic Sciences Centre
New Delhi, India
Harish Bhujade MD FVIR

Assistant Professor
Chandigarh, India
Jyoti Kumar MD DNB MNAMS FICR

Professor
New Delhi, India
Kartik Ganga MD
Fellow
Department of Cardiovascular Radiology and Endovascular Interventions
New Delhi, India
Kirti Gupta MD, Neuropathology Fellowship (St Jude, USA)

Professor
Department of Histopathology
Chandigarh, India
Kumble S Madhusudhan MD FRCR MAMS
New Delhi, India
Kushaljit Singh Sodhi MD PhD MAMS FICR

Professor
Chandigarh, India
Madhavi Tripathi MD DNB (Nuclear Medicine)

Department of Nuclear
Medicine and PET
New Delhi, India
Madhusudhan KS MD MAMS FRCR

New Delhi, India
Mahesh Prakash MD MAMS FIACM FICR

Professor
Chandigarh, India
Manavjit Singh Sandhu MD FICR CCST (UK)

Professor and Head
Chandigarh, India
Mandeep Garg MD FRCR

Professor
Chandigarh, India
Mandeep Kang MD MAMS FICR

Professor
Chandigarh, India
Manisha Jana MD DNB FRCR

New Delhi, India
Manish Modi MD DM
Professor
Department of Neurology
Chandigarh, India
Manphool Singhal MD DNB MAMS FICR (India) FSCCT (USA)

CMR-fellowship (London) CMR- Certification (SCMR USA and ESCVI France)
Chandigarh, India
Mukesh Kumar Yadav (MD Radiodiagnosis)

Formerly Associate Professor
PGIMER, Chandigarh
Associate Professor
All India Institute of Medical
Sciences (IRCH)
New Delhi, India
Naveen Kalra MD FICR MAMS

Professor
Chandigarh, India
Nidhi Prabhakar MD DNB

Senior Research Associate
Chandigarh, India
Niraj N Pandey DM
Assistant Professor
CN Centre
New Delhi, India
Niranjan Khandelwal MD Dip NBE FICR FAMS

Former Head
Chandigarh, India
Pankaj Gupta MD DNB

Assistant Professor
Chandigarh, India
Paramjeet Singh MD FICR

Professor
Chandigarh, India
Pratik Kumar PhD (AIIMS) Dip RP (BARC)

Professor, Medical Physics Unit
BRA Institute Rotary Cancer Hospital
AIIMS, New Delhi, India
Priya Jagia MD DNB

Professor
New Delhi, India
Priyanka Naranje MD DNB MNAMS

Associate Professor
New Delhi, India
Punit Sharma MD
Former Senior Resident
Department of Nuclear Medicine
New Delhi, India
Radhika Batra MD DNB

Associate Professor
New Delhi, India
Rajat Jain MD DNB FRCR FICR MNAMS

Assistant Professor
New Delhi, India
Raju Sharma MD MAMS FICR

Professor
New Delhi, India
Rakesh Kumar DRM DNB PhD

Professor and Head
Diagnostic Nuclear Medicine Division
Department of Nuclear Medicine and PET
New Delhi, India
Rakesh Kumar Vasishta MD FRCPath

Former Professor and Head
Department of Histopathology
Chandigarh, India
Rashmi Dixit MD
Director Professor
New Delhi, India
Sameer Vyas MD DM MAMS (Neuroradiology)

Chandigarh, India
Sanjay Sharma MD DNB MNAMS FRCR FICR

Professor
(Division at Rajendra Prasad Center for Ophthalmic Sciences)
New Delhi, India
Sanjeev Kumar MD
Associate Professor
New Delhi, India
Sanjiv Sharma MD
Professor and Head
Department of Cardiovascular Radiology
and Endovascular Interventions
CN Centre
New Delhi, India
Sapna Singh MD DNB MNAMS

Professor
New Delhi, India
Satyam DNB MNAMS

Specialist
Lok Nayak Hospital and Associated
New Delhi, India
Shailesh B Gaikwad MD FNAMS CCST

Professor and Head
Department of Neuroimaging and Interventional Neuroradiology
CN Centre
New Delhi, India
Shamim Ahmed Shamim MD (Nuclear Medicine)

Associate Professor
Department of Nuclear Medicine
New Delhi, India
Shashi Bala Paul PhD MAMS

Senior Scientist
New Delhi, India
Shivanand Gamanagatti MD MNAMS FICR

Professor
(Trauma Center Division)
New Delhi, India
Smita Manchanda MD DNB MNAMS

Associate Professor
New Delhi, India
Smriti Hari MD MAMS

Professor
New Delhi, India
Sreedhara BC MD FVIR
Assistant Professor
Chandigarh, India
Subrat Kumar Acharya DM FNASc FASc FNA JC Bose Fellow

Department of Gastroenterology
New Delhi, India
Sudesh Prabhakar MD DM
Department of Neurology
Chandigarh, India
Sudha Suri MD
Emeritus Professor
Chandigarh, India
Surabhi Vyas MD DNB MNAMS

New Delhi, India
Swati Gupta MD DNB FRCR

Associate Professor
New Delhi, India
Tulika Singh MD
Chandigarh, India
Ujjwal Gorsi (MD Radiodiagnosis)

Associate Professor
Postgraduate Institute of Medical
Education and Research
Chandigarh, India
Uma Debi MD
Associate Professor
Chandigarh, India
Veenu Singla MD
Professor
Chandigarh, India
Vikas Bhatia MD DNB

DM (Neuroradiology)
Assistant Professor
Chandigarh, India
Vineeta Ojha MD DNB

DM Senior Resident
New Delhi, India
Virendra Jain MD FRCR

Former Senior Resident
New Delhi, India
Vivek Gupta MD DM
Former Professor
Chandigarh, India
PREFACE
TO THE
THIRD
EDITION
In 1996, a unique venture was jointly initiated by the faculty of Radiodiagnosis, All India Institute
of Medical Sciences (AIIMS), New Delhi; Maulana Azad Medical College (MAMC), New Delhi; and
Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India, to organize
continuing medical education (CME) programs based on a series of imaging courses. An integral
part of this endeavour was publishing books covering all organ systems. The aim was to provide
state-of-the-art knowledge for postgraduate students as well as the practicing radiologists along with
establishing a uniform pattern of teaching in radiology across the country.
The first series of seven imaging courses was successfully completed in the year 2000. A second
series of these courses was then initiated in the year 2002 and was completed in 2004. This was also
highly successful. The third series of seven extremely popular and successful courses covering all the
organ systems and advances in physics was started in 2008 and was completed in 2013. The fourth
series started in 2016 and was completed successfuly in 2020.
Every course in each of the series has resulted in publication of a book. These books have been
very popular amongst residents as well as among practicing radiologists.
Considering the popularity of these books, the editors, along with publishers, M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, had decided to combine the individual course books
into three volumes— “AIIMS-MAMC-PGI's Comprehensive Textbook of Diagnostic Radiology”. Its first
edition was released in 2016.
In keeping pace with newer developments in the field of diagnostic radiology and in order to cater to
the contemporary needs of users, the second edition of “AIIMS-MAMC-PGI's Comprehensive Textbook
of Diagnostic Radiology” was presented in 2019 after a gap of three years. It was anticipated that with
such a complete coverage of all the subjects, the users will not have to refer to any other book during
their routine learning of diagnostic radiology.
However by the time fourth AIIMS MAMC PGI Imaging course series was near completion in early
2021, it was felt that there is a very strong need for updating of second edition along with addition of
new chapters in view of rapid advancement of knowledge in the last few years. So third edition was
planned. It was also agreed that in view of increasing size of individual course books and to keep the
size of individual volumes of the Textbook handy and managable the whole textbook should be divided
into four volumes from its current three volumes.
We are sure that residents and radiologists will find these comprehensive four volumes easy to
handle and very useful in day-to-day practice.
We are once again grateful to all the contributors from the three apex academic institutions of India,
i.e. AIIMS, New Delhi; MAMC, New Delhi; and PGIMER, Chandigarh, India.
We are thankful to M/s Jaypee Brothers Medical Publishers (P) Ltd, for helping us to make our
dream come true.
Arun Kumar Gupta
Anju Garg
PREFACE
TO THE
FIRST
EDITION
In 1996, a unique venture was jointly initiated by the faculty of radiodiagnosis at All India Institute of
Medical Sciences, Maulana Azad Medical College, New Delhi, and Postgraduate Institute of Medical
Education and Research, Chandigarh, India, to organize continuing medical education programs based
on a series of imaging courses. An integral part of this endeavor was publishing books covering all
organ systems. The aim was to provide state of the art knowledge for postgraduate students as well as
the practicing radiologists along with establishing a uniform pattern of teaching in radiology across the
country.
The first series of seven imaging courses was successfully completed in the year 2000. A second
series of these courses was then initiated in the year 2002 and was completed in 2004. This was also
highly successful.
With the great success of the second series, we, the current editors, decided to start a third series
of these courses in 2008. Seven extremely popular and successful courses covering all the organ
systems and advances in physics were completed in 2013.
Every course in each of the three series have resulted in publication of a book. These books have
been very popular amongst residents as well as among practicing radiologists.
Considering the popularity of these books, we, the three current editors, along with publishers M/s
Jaypee Brothers Medical Publishers (P) Ltd., decided to combine the individual books published so far
into a “AIIMS-MAMC-PGI’s Comprehensive Textbook of Diagnostic Radiology” with three volumes.
We are very happy to see the end result of this great effort.
We are sure that residents and radiologists will find these comprehensive three volumes easy to
handle and very useful in day-to-day practice.
We are once again grateful to all the contributors from the three apex academic institutions of India,
i.e. AIIMS, MAMC, New Delhi and PGIMER, Chandigarh, India.
We are thankful to M/s Jaypee Brothers Medical Publishers (P) Ltd., for helping us to make our
dream come true.
Niranjan Khandelwal
Veena Chowdhury
Arun Kumar Gupta
ACKNOWLEDGMENTS
We would like to put on record our deep appreciation and gratitude:
To Professors Manorama Berry, Sudha Suri and Veena Chowdhury (Past Editors) the three
pioneers who in 1996 took a bold initiative and started a unique teaching course now popularly known
as AIIMS-MAMC-PGI’s imaging course. By October 2020, four series, each series comprising of seven
courses, have been completed. This course series has become extremely popular and every course is
followed by the publication of a book which too is highly appreciated and popular.
To Professors Sima Mukhopadhyay, Sushma Vashisht and Niranjan Khandelwal who have been the
Editors of past series and who contributed to organizing the earlier courses in their capacity as Heads
of Departments.
To all the Associate Editors of the different course books who put in immense effort to bring the
books out on time.
To all the Authors who contributed chapters without whom we could not have collected such an
outstanding content of teaching and academic material.
To our respective hospitals for giving us the privilege and unique opportunity to work, which enabled
us to amass data from patients and document images of diverse diseases that provide the reader with
a wide spectrum of knowledge.
Our sincere and grateful thanks to Shri Jitendar P Vij (Group Chairman), Mr Ankit Vij (Managing
Director), Mr MS Mani (Group President), Dr Richa Saxena (Associate Director-Professional
Publishing), Ms Nedup Denka Bhutia (Development Editor) and Other staffs of M/s Jaypee Brothers
Medical Publishers (P) Ltd, New Delhi, India, for their untiring coordination efforts in the production of
this book.
We are very proud indeed at the culmination of two decades of these course series, to compile
and present them together in the form of these four volumes of “AIIMS-MAMC-PGI’s Comprehensive
Textbook of Diagnostic Radiology”.
Arun Kumar Gupta
Anju Garg
Volume 1
SECTION
1
Genitourinary Imaging
Imaging Techniques and Radiological Anatomy of the Upper Urinary Tract

Current Status of Nuclear Medicine in Urinary Tract Imaging
Renal Calculus Disease and Obstructive Uropathy
Renal Parenchymal Disease
Nontubercular Infections of the Urinary Tract
Tubercular Infection of the Urinary Tract
Renal Cystic Diseases
Renal Neoplasms
Renovascular Hypertension
Imaging of Renal Transplant
Imaging Techniques and Radiological Anatomy of Lower Urinary Tract
Urinary Bladder and Urethral Diseases
Imaging Techniques and Radiological Anatomy of Female Genital Tract
Benign Adnexal Disease
Malignant Ovarian and Tubal Disease
Benign Diseases of the Uterus and Vagina
Malignant Diseases of the Uterus and Vagina
Female Infertility
Imaging Techniques and Radiological Anatomy of the Male Genital Tract
Disorders of the Prostate Gland
Scrotal Diseases
Male Infertility and Erectile Dysfunction
Imaging of the Adrenal Gland
The Retroperitoneum
Urinary Tract Trauma
Nonvascular Interventions in the Urinary Tract
Vascular Interventions in the Genitourinary Tract
Imaging Techniques and

CHAPTER Radiological Anatomy of
1 the Upper Urinary Tract
Sapna Singh, Jyoti Kumar, Anjali Prakash
ANATOMY OF THE UPPER URINARY TRACT
The upper urinary tract consists of paired kidneys and the ureters. The kidneys develop from three
structures—the pronephros, the mesonephric, and metanephric ducts in that order. The pronephros
regresses by 4th to 8th week of gestation leaving no adult correlate while the mesonephric duct forms
the male genital structures. The ureteric bud and the metanephric blastema arise from the metanephric
duct in the 5th week of gestation. The metanephric blastema develops into Bowman’s capsule, the
convoluted tubules, and loop of Henle while the ureteric bud develops into ureter, the renal pelvis,
calyces, and the collecting ducts. The calyces arise due to repeated divisions of the upper end of the
ureteric bud and this forms the basis of the lobar structure of the kidney, each lobe consisting of a calyx
and the associated collecting ducts and renal cortex. The lobar outline becomes smooth by around 5
years of age owing to multiplication of the renal cortical cells. However, in about 5% of the individuals,
there is persistence of the lobar outline into adulthood.
It is during the 4th to 8th week of gestation that the kidneys migrate cranially from the pelvic region
where they develop. The cranial migration is due to the lengthening of the lumbar and sacral spine
during development so that the normal final position of the kidneys is upper lumbar region. They also
rotate medially by around 90° so that the renal pelvis lies on the anteromedial aspect of the kidneys.1
The lateral sacral branches of the aorta supply the pelvic kidneys but during ascent they acquire higher
lateral branches of the aorta. The definitive renal arteries are seen at the first lumbar disc (L1-L2) level.
If the inferior arteries do not regress, accessory renal arteries can be seen. Accessory unilateral renal
arteries are seen in 30% population and bilateral are seen in 10% with a higher frequency seen with
anomalies of ascent.2
The kidneys come to lie in the retroperitoneal space with the right kidney lower in position than the
left owing to the presence of the liver on the right. The normal kidneys should be 12–14 cm in length
and the difference between the two should not be more than 1 cm. In quiet respiration, the kidneys
move up and down 2–3 cm and much more in deep inspiration. The renal hilum is a vertical opening
on the medial aspect which contains the renal pelvis and renal vessels. The renal veins lie anterior to
the renal arteries which in-turn lie anterior to the renal pelves. In addition, the hilum also contains fat,
nerve fibers, and lymphatic channels which drain into the lateral aortic lymph nodal group.
Each kidney is divided into an outer renal cortex and an inner renal medulla.3 The medulla consists
of 8–16 renal pyramids (Fig. 1). Each renal pyramid in-turn contains the ascending and descending
limbs of the loop of Henle and the collecting ducts. The cortex contains the glomerulus and the proximal
and distal convoluted tubules. The apex of the renal pyramid projects into a calyx at the renal papilla.
The renal collecting system consists of 10–14 concave-shaped minor calyces. The lateral extensions
of the calyces is called the forniceal angle. Two to four minor calyces join together to form the superior,
middle, and inferior major calyces respectively from superior to inferior. The minor calyces drain into
the major calyx by a narrow neck/infundibulum. The major calyces in-turn drain into the renal pelvis
which continues as the ureter at the pelviureteric junction (PUJ).
FIG. 1: Schematic diagram of the structure of the kidney.

Variants of the Calyceal Anatomy

• Compound calyx: Here, the multiple single calyces fail to divide and form a single large calyx known
as the compound calyx. Here, several renal papillae which represent the apices of the renal
pyramids drain into a single calyx. Compound calyces are usually seen at the polar region, i.e. at
the upper or lower poles and are prone to reflux nephropathy.
• Complex renal calyces and megacalycosis: In megacalycosis, there is a greater number of calyces
than normal (>15). There is dilatation of some or all renal calyces with normal renal pelvis and
ureter. Renal calyces may have a blunted morphology, but this condition should not be confused
with papillary necrosis in which the number of calyces is not increased and necrosis tends to be
dissimilar from calyx to calyx.
• Calyceal diverticulum: It represents a focal extrinsic dilatation of a renal calyx. A calyceal
diverticulum connects to the calyceal fornix and projects into the cortex rather than the medulla.
Retroperitoneal Spaces
The kidneys have a tough fibrous capsule closely applied to the renal cortex all around except at the
hilum.
The kidneys are retroperitoneal organs and lie in a space called the perinephric space or the
perineal space. The perinephric space is a space bound by layers of fascia and is an important
determinant of the direction of disease spread. The fascia anterior to the kidneys is called the Gerota’s
fascia while the posterior fascia is called the fascia of Zuckerkandl. The space enclosed between the
anterior and posterior fascia is called the perinephric space (Fig. 2). In addition to the kidneys, the
space contains the adrenal gland, the upper ureter and the perinephric fat. As the kidneys ascend from
the pelvis to the abdomen, the perinephric fascia forms a cone with its apex pointing superiorly, the
apex being closed.3,4
The transversalis fascia lines the inferior aspect of the diaphragm, the inside of the abdominopelvic
cavity, anterolateral abdominal wall, the anterior aspect of the spinal column, the psoas and paraspinal
muscles, and the superior aspect of the pelvic diaphragm. There is a potential space between the
posterior perinephric fascia and the adjacent transversalis fascia. This space is called the posterior
pararenal space and contains only fat (Fig. 2). The posterior pararenal space is of interest to the
radiologist as a guidewire may kink in this area or a drain intended for the pelvicalyceal system may be
accidently positioned here. The anterior pararenal space, on the other hand, is the space between the
anterior perinephric fascia and posterior layer of the peritoneum. In the center of the anterior pararenal
space lie the pancreas and duodenum, the ascending colon lies to the right and descending colon to
the left. These organs are hence in direct contact with the anterior perinephric fascia.4
Laterally, the anterior and posterior perirenal fascia fuse with the lateroconal fascia at the fascial
trifurcation. While the posterior pararenal space is continuous laterally with the lateral extraperitoneal
space (the properitoneal line) lying between the parietal peritoneum and transversalis fascia, this space
is closed medially. Medially, the posterior perinephric fascia fuses with the transversalis fascia over the
paraspinal muscles, that is the psoas muscle and the quadratus lumborum. The posterior perinephric
space hence lies directly over the psoas muscle being separated only by the transversalis fascia. Thus,
any inflammation process of the kidneys can spread rapidly into the psoas muscles and from there into
the iliacus muscle, iliopsoas, and the pelvis.
Thus, superiorly the renal fascia fuses with the diaphragmatic fascia. Laterally, the renal fascia
fuses with the lateroconal fascia and inferiorly with the iliac fascia blending loosely with the periureteric
connective tissue. Owing to the loose blending of the fascia, the inferomedial angle adjacent to the
ureter is the weakest point of the perinephric compartment through which urine or perinephric effusion
escapes most easily. The posterior renal fascia fuses with the psoas and quadratus lumborum fascia
medially.
The perineal spaces also communicate with each other across the midline and with the
retroperitoneal vascular space. The pararenal spaces communicate caudally and with the
extraperitoneal spaces including the prevesical space. Infections from one space can hence spread
to the other subsequently. The anterior interfascial or the retromesenteric space and the posterior
interfascial or retrorenal space are potential spaces within the laminated anterior perinephric and
posterior perinephric fasciae, respectively (see Fig. 2).5 The perirenal space contains thin septations
called the Kumin’s septa. These septae may arise from the renal capsule and extend to the anterior
and posterior renal fascia. Some may arise from the renal capsule and run parallel to the renal surface.
The renorenal bridging septum is the most consistent which arises from the posterior renal capsule
and runs parallel to the posterior surface of the kidney. These septae thicken consequent to a disease
process, what is referred to as perinephric stranding. These fibrous septae act as potential conduits
between the perinephric and interfascial spaces. Fluid and collections may track from any of these
potential spaces to the other and also via the fascial trifurcation into the lateroconal fascia.
FIG. 2: Diagram showing the retroperitoneal fascial spaces.

Relations of the Kidneys

The right kidney is related anteriorly with the inferior surface of the liver and the second part of the
duodenum while the anterior relations of the left kidney are the pancreatic tail, the spleen, the stomach,
the small bowel, the splenic flexure, and the left colon (Fig. 3).4 Posteriorly, the diaphragm, psoas
muscle, aponeurosis of the transverses abdominis muscle, and the lumbar muscles are related to the
kidneys. Both the kidneys are related superiorly with the adrenal glands while inferiorly the hepatorenal
pouch/Morrison’s pouch separates the right kidney from the inferior surface of the liver.
Vascular Anatomy
The renal arteries arise from the aorta, slightly below the origin of the superior mesenteric artery (SMA).
The right renal artery (RRA) arises from the anterolateral aspect of the aorta and then passes posterior
to the inferior vena cava (IVC) as it courses toward the right renal hilum. The left renal artery (LRA)
arises from the lateral or posterolateral aspect of the aorta and follows a posterolateral course to the
left renal hilum. Accessory renal arteries may arise from the aorta in as many as 20% individuals, either
superior or inferior to the main renal artery. The renal arteries typically divide into anterior and posterior
divisions that lie anterior and posterior to the renal pelvis, respectively. These divisions give rise to the
segmental arteries which branch further within the renal sinus, forming interlobar arteries that penetrate
the renal parenchyma. These terminate in arcuate arteries that curve around the corticomedullary
junction giving rise to cortical branches.3,4
Each renal vein is formed from tributaries that coalesce in the renal hilum. The left renal vein passes
anterior to the aorta and posterior to SMA, to enter the left side of IVC. The right renal vein, which is
shorter, extends directly to the IVC from the right renal hilum.
The lymphatic drainage is to the lateral aortic lymph nodes around the origin of the renal arteries.
Ureters
The ureter runs down the anterior aspect of the psoas muscle, the transversalis fascia separating the
two. The ureters run within 1 cm of the lateral margin of the vertebral transverse processes. At the level
of the sacroiliac joint, it crosses over the anterior aspect of the bifurcation of the common iliac artery
as it enters the pelvis. It then runs along the lateral pelvic wall just medial to the obturator internus
muscle. At the level of the ischial spine, it runs anteromedially until it enters the superolateral angle of
the bladder base. In males, the vas deferens crosses over the ureter just before it enters the bladder
wall. The ureters run obliquely for around 2 cm through the bladder wall.4
The ureters have three normal constrictions which act as points of temporary peristaltic arrest which
are as follows:
1. At the ureteropelvic junction
2. Crossing the iliac vessels
3. At the pelvic inlet.
IMAGING TECHNIQUES OF THE UPPER URINARY TRACT
CONVENTIONAL RADIOGRAPHY
The conventional plain radiography of the abdomen is an imaging technique for the kidneys ureter
and bladder also known as the kidney, ureter, and bladder (KUB) film.6 The kidneys are visible on the
plain radiograph due to natural contrast provided by the perirenal fat. An idea about the renal shape,
margins, dimensions, and localization can be made on the plain radiograph. It can also be used to
identify renal calculi, calcifications or transparencies due to fat or gas.7 The psoas shadow can also
be seen on the plain radiograph. Radiopacities seen on the plain radiographs correspond to the renal
stones or calcifications due to tuberculosis, vascular structures or traumatic lesions like hematoma
(Figs. 4A and B). Calcifications seen in solid or cystic neoplasms may also be seen on plain radiograph
(Table 1). The radiolucencies correspond to gas, e.g. emphysematous pyelonephritis or fat, i.e. large
angiomyolipoma (AML) or liposarcoma.
FIG. 3: Schematic diagram of the anterior relations of the right and left kidney.
FIGS. 4A AND B: (A) Plain X-ray of kidney, ureter, and bladder (KUB) showing a large radiodensity in the left renal
area suggestive of a left renal calculus; (B) Another plain film showing multiple radiopacities in the left renal area
suggestive of multiple renal calculi.
TABLE 1: Calcification on the KUB.4

Urinary tract
Renal: Calculi, tuberculosis, renal cell carcinoma, and arterial atheroma or aneurysm
Ureter: Calculi, tuberculosis, and schistosomiasis
Bladder: Calculi, transitional cell carcinoma, and schistosomiasis
Outside the urinary tract
Hepatobiliary: Gallstones and hepatic granuloma

Spleen: Granuloma
Pancreas: Chronic pancreatitis
Adrenal: Tuberculosis and Addison’s disease
Aorta: Atheroma and aneurysm
Venous: Phlebolith
Musculoskeletal: Costal cartilage calcification
Uterine: Fibroid
Lymphatic: Calcified lymph nodes (presumed postinfective)
(KUB: kidney, ureter and bladder)
INTRAVENOUS UROGRAPHY
Intravenous urography (IVU), also known as the excretory urogram is a time-tested technique of
uroradiology providing a global view of the renal parenchyma and collecting system.8
Indications:
• Urolithiasis
• Ureteric fistulae/strictures
• Renal infections, e.g. tuberculosis. IVU still remains the gold standard in the imaging of renal
tuberculosis. It is the only modality that can detect early changes in the renal calyces in
tuberculosis, e.g. early fuzziness, irregularity of calyces, papillary necrosis, etc.
• Persistent or frank hematuria.
Normal Physiology Giving Rise to the Appearances on IVU

Intravenous urography consists of a series of plain films following intravenous injection of water soluble
iodinated contrast medium.9 The contrast reaches the renal arteries 12–20 seconds following contrast
injection. The concentration of the contrast material is maximum in the vascular compartment at
this stage, but it begins to fall rapidly as it enters the extracellular compartment. It also undergoes
glomerular filtration and enters the renal tubules. Hence, in the first minute following contrast injection,
there is a diffuse enhancement referred to as the nephrogram phase provided the kidneys are healthy
with the patient having a normal cardiovascular system. The renal size and outline are best evaluated
in the nephrogram phase, the normal renal length being at least three lumbar vertebrae and not
exceeding four. Contrast then begins to appear in the calyces around 1 minute which subsequently
drains into the pelvis and ureter referred to as the pyelogram phase. The normal ureters demonstrate
continued peristalsis and it may not be possible to visualize the entire length of both (or even one)
ureters in a single film. In most cases, partial visualization of the ureters is acceptable.
Technique
Traditionally, patients were deprived of fluid before an IVU examination with the belief that it would
lead to a better opacification of the collecting system. However, it has long been established that
dehydration is associated with an increased risk of nephrotoxicity and should be completely avoided.
In fact, if the patient is dehydrated before the IVU, it needs to be corrected first. Food should be
avoided 4–6 hours prior to the examination and bowel preparation (using laxatives) is preferable to
avoid gases overlying the renal shadows. The patient is called fasting (4–6 hours) and with adequate
bowel preparation but should be well hydrated. A plain radiograph (KUB) is must as it gives an idea
of the bowel preparation and is needed to follow up a previously proven calculus. A preliminary KUB
also gives an idea of exposure factors, correct positioning/centering, and any obvious pathology, most
common of which is urinary tract calcification.
Blood urea and serum creatinine levels should be checked before contrast administration as the
risk of contrast-induced nephropathy is increased if serum creatinine is greater than 1.5 mg/dL. Also,
in patients with impaired renal function (serum creatinine greater than 3.5 mg/dL), the excretion of the
contrast material and subsequent renal and ureteric visualization are limited.
If the patient is fit to undergo the examination, contrast is injected at the dose of 1 mg/kg body
weight. The standard dose is usually 50 mL of 350–370 mgI/mL water soluble iodinated contrast
medium. Although usually safe there is a small risk of reactions.10 The most severe reaction that can
occur following contrast administration is anaphylactoid type hypersensitivity reaction. Hence, before
injection of contrast medium, a history of allergy to any previous contrast exposure should be elicited.11
The injection should be administered through an indwelling cannula that can be kept in place for the
entire duration of the investigation. This would allow any emergency treatment to be given in case of
an eventuality. Also, in cases of poor contrast opacification, a further dose of contrast medium can be
administered. Most contrast reactions take place within the first few minutes following contrast injection.
Emergency drugs, oxygen, and resuscitation should be available in the IVU room. The radiologist
should be available in the X-ray room for the entire duration of the procedure.
Sequence of films taken
Abdominal compression is applied after the 5-minute film to improve the distention of the
pelvicalyceal system by inhibiting ureteric drainage. However, compression should not be applied
in children, in patients of hypertension/aortic aneurysm, those with recent abdominal surgery or
abdominal pain or tenderness. After 15-minute film with compression, the compression is removed
and full length films are taken in the supine and prone positions, the prone position allowing a better
visualization of the pelvic ureters (Figs. 5A to C).
At times, a delayed film needs to be taken in cases of significant acute obstruction where there is
a delay in the opacification of the pelvicalyceal system. This follow-up IVU needs to be done till a time
when the contralateral kidney has completely excreted the contrast.
FIGS. 5A TO C: (A) Plain X-ray of kidney, ureter, and bladder (KUB) showing multiple left renal calculi and
radiodensity in the line of the right ureter suggestive of left ureteric calculus; (B and C) Intravenous urography images
showing renal calculi as filling defects within the opacified left pelvicalyceal system and the right ureteric calculus.
Note is made of the upper ureter being dilated and tortuous with a characteristic medial angulation suggestive of
retrocaval ureter.
With the advent of cross-sectional imaging, the utility of IVU is a topic of considerable debate.12
Computed tomography (CT) scores over IVU for urolithiasis with a sensitivity of 100% versus 52–69%
for IVU.13 In one review, patient acceptability, superior diagnostic performance of CT versus IVU,
equivalent radiation doses using low-dose techniques in CT were the factors for recommending CT
over IVU.14 CT is also superior to IVU for urinary tract tumor detection with sensitivities of only 21%,
52%, and 85% for masses less than 2, 2–3, and greater than 3 cm, respectively on IVU.15 However, a
blanket substitution of IVU by cross-sectional imaging is not feasible due to cost and availability factors.
DIGITAL TOMOSYNTHESIS
Digital tomosynthesis (DT) is a technique that enables visualization of stones from multiple angles
rather than simply anterior to posterior. The technique involves acquisition of images at regular intervals
at different angles during a single linear or arc sweep of the X-ray tube. The images can then be
reconstructed providing better resolution than conventional radiography. Compared with CT, DT offers
a reduced radiation exposure, higher in plane resolution, easier availability, and lower cost. In a study
done to evaluate the accuracy of IVU using DT, a significant improvement was seen from 46.5% for
conventional IVU to 95.5% for IVU with DT.16 There was a dose reduction of 56% and a decrease
in the length of the procedure.16 This technique may be useful in situations such as evaluation of
residual stone after percutaneous lithotripsy, that is, in situations where a detailed imaging of the renal
parenchyma is not required. DT is currently an experimental technique and may play a role in KUB
radiography remaining an important technique in kidney stone imaging in the future.
RETROGRADE PYELOGRAPHY
Retrograde pyelography (RGP) involves opacification of the pelvicalyceal system retrogradely by
instillation of contrast medium into a ureteric catheter placed by cystoscopy. With the advent of
multidetector computed tomography (MDCT) with isotropic data acquisition and multiplanar
reconstruction, the role of RGP is limited.17
The indications include:
• As a problem-solving tool in cases of persistent diagnostic uncertainty, especially if there is
hematuria and/or suspicious cytology.18
• To confirm or negate the presence of one or more filling defects within the collecting system.
• To demonstrate the lower end of an obstructed ureter.
Technique
Catheters are positioned within one or both ureters cystoscopically by the urologist. Under fluoroscopic
screening, 5–20 mL of water-soluble iodinated contrast medium is injected via the catheter. Care
should be taken so as to not inject air bubbles as these can be mistaken for filling defects. The ureters
and pelvicalyceal system are hence opacified retrogradely. These should be opacified adequately but
not overdistended as a forceful and excessive contrast injection can lead to reflux of contrast into the
collecting ducts (pyelotubular reflux), contrast extravasation into the renal sinus (pyelosinus reflux),
forniceal rupture, and even into the regional lymphatics or veins (pyelolymphatic and pyelovenous
reflux).
ANTEGRADE PYELOGRAPHY
It is a simple invasive procedure used to evaluate the cause and level of ureteric obstruction where
other imaging modalities have failed to do so. The technique involves positioning the patient 45°
semiprone and puncturing the pelvicalyceal system with a fine (22 gauge) needle under fluoroscopy
or ultrasound guidance. The puncture should be directed through the renal parenchyma into a suitable
calyx and then into the pelvis.4 Aspiration of urine can confirm the cannulation. Water-soluble contrast
medium is then injected to opacify the pelvicalyceal system. A series of spot films of the ureter down to
the level of obstruction can be taken.
NEPHROSTOGRAM
A nephrostomy tube is usually positioned for therapeutic purposes but contrast can be instilled through
it and a nephrostogram can be performed. It is indicated to assess the continued presence of calculus
or any obstructing lesion or determine the cause of obstruction if it has not been demonstrated.
Nephrostogram is also done in post-operative patients of PUJ obstruction to check the patency.4 It is
used to monitor the status of fistulas. Spot films of the ureter are taken down to the level of obstruction.
GRAYSCALE ULTRASOUND
Ultrasound is a reliable technique for the evaluation of upper urinary tract. It is noninvasive, easily
available, accurate, safe, and does not require exposure to ionizing radiation. It can be performed
bedside for sick patients and interventions can be performed under ultrasound guidance.
Indications for sonography in upper urinary tract:19
• Diagnosing dilatation of the collecting system and to search for renal obstruction.
• Excellent modality for evaluation of cystic renal lesions. Their architecture including internal
septations, wall thickening, calcifications, presence or absence of solid components (in order to
assign a Bosniak grade) can all be evaluated on ultrasound.
• Assessment of congenital anomalies and renal infections as ultrasound is a safe method for
evaluating the urinary tract particularly in pediatric patients as high resolution sonography is easily
feasible and radiation can be avoided.20,21
• Postnatal ultrasound for the evaluation of urinary tract in documented prenatal fetal hydronephrosis.
• Characterization of renal masses.
• Detection of nephrolithiasis and resultant back pressure changes, if any.
• Painless hematuria in low- and medium-risk patients.22
• Guidance for therapeutic and interventional procedures.
FIGS. 6A AND B: (A) Longitudinal and (B) transverse views of the kidney on ultrasound showing bright central sinus
echoes, the cortex, and the hypoechoic medulla.
Technique
Positioning and Access
A 3–5 MHz curvilinear/linear transducer is used to scan the kidneys and ureter. A supine or lateral
decubitus position can be adopted for kidneys. The right kidney is usually examined first where the liver
is used as an acoustic window (Figs. 6A and B). The transducer is placed in subcostal or intercostal
position. Owing to gases from the small bowel and splenic flexure visualization of the left kidney
becomes difficult at times via anterior or anterolateral approach. In such situations, a posterolateral
approach can be adopted for the left kidney with the left side of the patient raised by approximately
45°.23 The spleen provides an acoustic window on the left side. If even after raising left side of the body
by 45°, visualization is not successful, a full right lateral decubitus with the pillow under the right flank
and the left arm extended over the head may allow visualization of the left kidney. Prone position is
usually adopted for young children for adequate visualization of the kidneys. A prone position is useful
in adults in ultrasound-guided procedures.24
Renal Size
The longest craniocaudal length should be measured by rotating the probe around its vertical axis. The
longest length should be measured as false low measurements are obtained at times due to ellipsoidal
shape of the kidney. Renal length which gives an estimate of the overall renal size is quick and easy to
measure. The determination of renal size with ultrasound is more accurate than with IVU because the
kidney is imaged without magnification and contrast-induced osmotic diuresis. As a result renal size is
approximately 15% smaller. Renal size is related to sex, age, and built of the patient. The length of the
normal adult kidney is usually 10–12 cm but can range from 7 cm to 14 cm in patients with normal renal
function (Table 2). Length can also vary in the same individual depending on the state of hydration.
TABLE 2: Normal kidney length in adults.25

Adult female (cm) Adult male (cm)
Left kidney 11 (9.9–12.1) 11.5 (10.4–12.6)

Right kidney 10.7 (9.5–12) 11.2 (10.1–12.4)
Where an absolute accurate estimate of the size of the kidneys is necessary, the renal volume can
be measured. This can be achieved by measuring the area of the kidney in serial slices and calculating
the volume but this method is very time consuming. A modified three-dimensional (3D) ellipsoidal
formula is utilized where the length, anteroposterior diameter, and transverse diameters are multiplied
by a constant which is approximately 0.5.19 Volume measurements are done in postnephrectomy,
patients to look for compensatory hypertrophy and in the assessment of renal transplants.
Emamian et al. measured the renal size in 665 healthy adult volunteers and showed that the
parenchymal volume of the right kidney is smaller than the left.26 Possible explanation for this could
be: (1) The spleen is smaller than the liver and so there is more space for left kidney growth and (2)
The LRA is shorter than the right and, therefore, increased blood flow on the left results in an increase
in renal volume.
Cortical and Parenchymal Thickness

The cortical thickness is the distance between the renal capsule and outer margin of the renal pyramids
while parenchymal thickness is the distance between renal capsule and margin of the sinus echoes
(Fig. 7).
Perirenal Structures
An assessment of the perirenal fat, pararenal areas, and adrenal areas should be done. At times, in
case of any renal abnormality, liver, pancreas, lining of ureters, pelvis, and bladder may need to be
examined.
FIG. 7: Ultrasound image showing the normal cortical thickness (++) measured from the renal capsule to the outer
margin of the medullary pyramids and the parenchymal thickness (xx) from the capsule to the margin of the sinus.
The parenchymal thickness is more than the cortical thickness.
FIG. 8: Ultrasound scan of the kidney showing the corticomedullary differentiation well with the medulla seen as
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Rakastuneet menivät sivuhuoneeseen, saadakseen olla kahden
kesken. Katri tuli puhumaan kihlauksesta ja häävalmistuksista. Minä
sanoin, että se oli liian varhaista, ja käskin hänen mennä suohon.
Hän ei kuitenkaan mennyt pitemmälle kuin keittiöön.
Mutta nyt alkoi seinän takaa kuulua naurua ja tukahtunutta

läiskinää. Raotin hiljaa ovea ja huomasin, että nuoret olivat ottaneet
itselleen vapauksia, jotka kuuluivat rakkauden myöhempään
kehityskauteen. Yllätin heidät äkkiä, otin ankaran muodon ja sanoin:
"Vai niin, te varastatte täällä suudelmia etukäteen!"
Rakastuneet karahtivat tulipunaisiksi ja katselivat hämillään toinen

lattiaan, toinen kattoon. Mutta minä jatkoin:
"Minä olin tuntenut nykyisen vaimoni viisi vuotta, eikä päähänikään

pälkähtänyt suudella häntä ennen kuin olimme julkikihloissa."
"Sinä hävytön valehtelija!" torui Katri, joka huomaamattani oli

hiipinyt selkäni taakse.
Nyt oli minun vuoroni punehtua.
"No, jos joskus otin pikku muiskun, tein sen siksi, että sinun teki
niin kovin mielesi."
"Ohoo, isäseni! Vai teki minun mieleni! Tämä menee liian pitkälle!"
soimasi Katri ja antoi nuorille rohkaisevia silmäniskuja aivan kuin
olisi sanonut: muiskailkaa te vaan, ei siitä huulet kulu!
Huomasin enemmät estelyt turhiksi sen jälkeen kun olin näin

häpeällisellä tavalla tullut paljastetuksi, ja jätin nuoret rauhaan.
Jonkun viikon kuluttua vietettiin nuorten kihlajaisia. Setä Samuli
sai kutsun; hän olisikin muutoin loukkaantunut kauheasti.
Huomatessaan, että poika n:o 2 oli nähnyt päivänvalon, ei hänen
paheksumisellaan ollut mitään rajoja. Hän sanoi paljon muun hyvän
ohella:
"Niinhän se on kuin minä aina olen sanonut: minun

vaatimattomimpiakaan toivomuksiani ei oteta varteen. Ja kuitenkin
olen auttanut teitä yhdessä ja toisessa asiassa. Mutta
kiittämättömyys on maailman palkka!"
Emme voineet puolustaa itseämme. Ainoaksi lohdutukseksi

saatoimme huomauttaa sedälle, että parannus ei kenties vielä ollut
myöhäistä, mutta siihen hän ei tuntunut paljoa luottavan.
Tietysti piti Sirkan kihlajaisissaan laulaa. Sen hän tekikin ilolla, ja

minusta tuntui, ettei hän konsertissakaan ollut sellaisella hartaudella
laulanut.
Katri puuhasi kuin paras emäntä konsanaan. Kesken kaiken hän

kysyi:
"Mutta sanoppa, Sirkka, miten tavoitit niin äkkiä uuden sulhasesi?"
Tyttö nauroi.
"Jättäydyitkö sinä aikoinasi yhden varaan! Minä tunsin tämän

ennen kuin sen edellisen."
Minä huomautin, että nuoret tytöt valinnassaan usein erehtyvät:

jättävät hyvän ja ottavat huonomman. Sirkka sanoi:
"Valitettavasti minäkin annoin turhamielisyyden johtaa itseäni
harhaan.
Suostuin siihen, jolla oli sileämpi ulkokuori ja liukkaammat sanat.
Onneksi tuli onnettomuus ja paljasti miehen todellisen olemuksen."
Katria alkoi naurattaa.
"Missä se entinen varatuomari nyt on? Hänen isänsä piti olla

valtioneuvos ja ties mitä kaikkea."
"Hän oli yhtä paljon tuomari kuin hänen isänsä valtioneuvos.

Rappiolle joutunut ylioppilas, joka oli laiskotellut yliopistossa muka
lakitiedettä lukien."
Minulla oli puheenvuoro.
"Hän uhkasi vetää minut oikeuteen tulevan vaimonsa omaisuuden

hukkaamisesta. Tähän päivään mennessä ei haastetta ole kuulunut."
Lopuksi en malta olla mainitsematta, että setä osoitti kihlatuille

suurta huomaavaisuutta. Melkein tuntui siltä kuin hän olisi alkanut
kohdistaa toivomuksensa sinnepäin, koska Katri ja minä olimme
pettäneet hänen luottamuksensa. Saattoi pitää päätettynä asiana,
että hän Sirkan hääpäivänä olisi paikalla reumatismineen ja
shekkikirjoineen.
Katri ja minä elimme Sirkan onnessa uudelleen ensi rakkautemme

ja kihlauksemme ihania kevätaikoja…
YHDEKSÄSTOISTA LUKU.
Madonna ja lapsi.
Taaskin oli pari onnellista vuotta vierinyt. Meillä oli sillävälin ollut
sanomalehdessä ilmoitus:
"SYNTYNYT.
Jumala lahjoitti meille terveen pojan.
Katri ja Kalle ———."
Se oli kolmas järjestyksessä. Voitte arvata, miten setä Samuli

irvisti, jos sattui tuon tiedonannon lukemaan, mikä on enemmän kuin
luultavaa, sillä hän tutki hyvin tarkkaan lehtien ilmoitusosaston.
Sirkkaa on jo vuoden sanottu tohtorinrouva Valtimoksi. Hän jatkaa

uutterasti lauluopintojaan ja esiintyy usein omissa konserteissa tai
avustajana monenlaisissa tilaisuuksissa. Tohtori Valtimo on etevä
amatööri, joka soittelee viulua ja säestää vaimoansa. Heidän
onnestaan ei puutu muuta kuin… Mutta kunhan aika tulee…
Viisastuneena katkerista kokemuksistani epäilin ryhtyä
toistamiseen vakinaisen kodin perustamiseen, mutta kun sain tietää
eräästä luotettavien henkilöiden muodostamasta asunto-
osakeyhtiöstä, liityin siihen kuitenkin osakkaaksi. Enkä ole
kauppaani katunut. Tohtori Valtimokin on yhtiömiehenä ja lähimpänä
naapurinamme. Me muodostamme yhteisen suuren perheen, joten
meillä on joka päivä tilaisuus kuulla Sirkan laulua ja hänellä leikkiä
lastemme kanssa, joita hän niin paljon rakastaa.
Teimme juuri muuttoa uuteen taloon. Saimme vielä kerran ahertaa

oman kodin rakentamispuuhissa; se oli rasittava tehtävä, mutta
samalla rakas ja toivoa herättävä. Huonekalut olivat jo järjestetyt, ja
Katri asetteli uutimia paikoilleen. Minä autoin häntä pitäen kiinni
tuolia, jolla hän seisoi. Ikkunastamme oli laaja, ihana näköala yli
meren rannattoman ulapan. Aurinko meni lännessä mailleen, ja illan
varjot alkoivat laskeutua yli meluavan kaupungin.
Tuntui kuin olisi joulu tai juhannus ovella.
Saatuaan työnsä valmiiksi hypähti Katri alas ja horjahtui

putoamaan syliini. Laskin hänet hellästi maahan.
Istuuduimme sohvalle ja katselimme ääneti toisiamme. Poveamme

paisutti onni niin syvä ja täyteläinen, että mitkään sanat eivät kykene
sitä ilmaisemaan. Vihdoinkin, vihdoinkin olivat murheen mustat pilvet
poistuneet ja riemun päivä paistoi täydeltä terältään.
"Minusta tuntuu kuin olisi onnemme tullut aivan odottamatta",

puhkesi
Katri vihdoin puhumaan.
"Odottamatta, niin, mutta ei aivan ansiotta. Olemmehan ostaneet
sen vuosien pettymyksillä ja raskailla kärsimyksillä."
Hämärtyvässä huoneessa näin kyyneleen päilyvän Katrin

silmänurkassa.
"Kun muistelen menneitä, raskaita aikoja, tuntuu minusta kuin

kaikki olisi pahaa unta tai kauhea painajainen."
"Samoin minustakin. Ja tuntuu lisäksi kuin ei meidän sopisi syyttää

ketään tai olla katkera kellekään. Kaikki on ollut meidän
hyväksemme. Sillä se, joka on kestänyt onnettomuuden, ymmärtää
oikein käyttää onneakin."
Katri nyökkäsi ääneti ja ymmärtävästi ja sanoi hiljaa:
"Oletko antanut anteeksi niille, jotka ovat olleet syyllisiä

kärsimyksiimme?"
Minä nyökkäsin vuorostani.
"Sillekin, joka istuu…"
Sen nimen paljas muisto riitti täyttämään minut kauhulla. Vastasin:
"Se kurja hylkiö oli tietämättään Sallimuksen kädessä välikappale,

jonka avulla uusi onnemme luotiin."
Me istuimme kauan. Sydämeni oli niin täysi, että oli vaikea olla
puhumatta.
"Miten olisi minun käynyt, ellet sinä olisi ollut minua tukemassa,
Katri! Sinua minun tulee kiittää kaikesta."
Hän vastasi:
"Muistatko hetkeä, jolloin päätimme mennä naimisiin ja puhelimme

toimeentulostamme? Sinä arvelit, että alussa tulisimme paljaalla
rakkaudella toimeen."
"Ja sinä vakuutit, että rakkaus auttaa meitä vaikeuksissa. Nyt

huomaan, miten oikeassa sinä olit. Rakkaus se antoi meille voimaa
elämään silloin kun kaikki olivat meidät hyljänneet ja velkojat,
haastemiehet ja ulosottajat olivat ainoat, jotka meitä käynnillään
kunnioittivat."
Esikoisemme, joka jo käveli, vaikka mieluummin neljällä jalalla,

konttasi sisään ja alkoi kiskoa pöytäliinaa. "Katri kielsi, mutta
poikavekara ei ollut millänsäkään vaan raastoi kaikin voimin. Silloin
Katri torui:
"Jos ei Kullervo tottele, niin huijari tulee!"
Säikähtyneenä juoksi lapsi äitinsä luo, kätki päänsä helmaan ja

jokelsi;
"Tulekot huijati nyt?"
"Ei, jos Kullervo on kiltti, niin huijari ei tule."
"Miksi olet ruvennut peloittelemaan lasta huijarista puhumalla?

Näethän, miten se vapisee", sanoin minä.
Hän silitti hellästi lapsen päätä ja sanoi:
"Minusta on mieletöntä säikyttää lapsia möröillä ja pöröillä, joita ei

ole olemassa. Huijari sitävastoin on todellinen, ja on hyödyllistä jo
lapsena oppia tuntemaan, että se on kauhea olento, joka tekee
pahaa."
Sitte hän meni ja toi sylyksen puita ja latoi pesään. Olimme siksi
vanhanaikaisia, että pidimme runollista, räiskyvää takkavalkeata
kaikkia kehuttuja keskuslämmityslaitoksia parempana.
Pian leimusi pesässä iloinen tulennos. Aioin sytyttää lampun,

mutta Katri sanoi, että hämärässä istuminen oli rattoisaa, etenkin
kun me vietimme ensi iltaa kodissamme.
Nuorin lapsi heräsi. Hän otti pienokaisen syliinsä, siirsi tuolin takan
ääreen ja istui antaen loimottavan pystyvalkean lämmittää lasta.
Ilta oli pimennyt. Kadulla syttyi lyhty toisensa perästä. Meren pinta
välkehti iltaruskon sammuvassa hohteessa, ulapalla kynti laiva
aaltoja kymmenien tulien tuikkiessa.
Kun taas käännyin ja loin katseeni Katriin, joka istui lapsi sylissä
syrjittäin minuun, näin kuvan, joka monin verroin voitti edellisen.
Siinä oli jotakin niin tutunomaista, kodikasta, elettyä, että minä aivan
hätkähdin ja kysyin itseltäni, missä olin ennen nähnyt samanlaista.
Äkkiä, vaistomaisesti minulta pääsi huudahdus:
"Madonna!"
Katri katsoi minuun hymyillen:
"Joko sinä taas uneksit?"
"En, tämä on todellisuutta, ihanaa todellisuutta. Asetu niinkuin olit

äsken, niin olet ihan ilmetty… Kas niin! Nyt on arvoitus selvinnyt:
madonna olet sinä!"
Katri nauroi:
"Sädekehää vain vailla, — pyhyyden loistetta."
"Rakkauden ja uskollisuuden sädekehä ympäröi päätäsi. Pitäkööt

pyhimykset ja enkelit kruununsa, minun silmissäni sinulla on loisto,
jota ei mikään maallinen eikä taivaallinen kirkkaus himmennä."
Huone oli pimennyt. Vain hiilivalkean himmenevä hehku levitti

salamyhkäistä kimmellystään. Minä tunsin sillä hetkellä sielussani
jotain niin korkeata, suurta, pyhää, että tuntuisi loukkaukselta yrittää
pukea sitä sanoihin.
Nyt kuulin liikuntaa seinän takaa. Sirkka oli palannut kaupungiltapa

käveli huoneessa, hyräillen ihanalla äänellään. Sitte hän avasi
pianiinon. Muutaman valmistavan akordin jälkeen hän alkoi laulaa —
laulaa madonnalaulua. Kuulimme selvään:
"On ilta, päivä mailleen käy,

mut ystävääni ei vain näy.
Oi etkö helly itkustain!
Madonna, kuule huutoain!"
Ihmeellinen liikutus valtasi minut.
"Katri, kuulehan! Noin kauniisti hän ei ole ikänä madonnasta

laulanut."
Katri nyökkäsi hiljaa. Taas soi laulu:
"Oot puhdas yli kaikkien,

mut minä kurja syntinen.
Ah, jospa pyhyytes ma sain!
Madonna, kuule huutoain!"
Kuului muutama vihlova sointu, mikä kohta suli vienoon,

hyräilevään pianissimoon, jonka kaiku etääntyi, kuoli pois kuin
väsynyt laine rannan ruohikossa…
Hiilloskin oli riutunut. Sen viimeinen hohde kajasti Katrin kasvoille

ja siitä lapseen.
"Nyt tiedän varmaan, että madonna tuottaa onnea", sanoin minä.
Hän vastasi hymyillen:
"Ehkä on niin. Sen minä ainakin tiedän, että madonna on itse

onnellinen, sillä se rakastaa."
Ja hän puristi lasta rintoihinsa niinkuin Jumalan äiti kuvassa.
"Sinä olet oikeassa: madonna rakastaa, siksi se on onnellinen",

sanoin minä. "Rakkaus yksin tekee onnelliseksi!"
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Niranjan Khandelwal MD Dip NBE FICR FAMS

Pankaj Gupta MD DNB

Paramjeet Singh MD FICR

Pratik Kumar PhD (AIIMS) Dip RP (BARC)

Priya Jagia MD DNB