Diagnostic Radiology - Uroradiology

MBBS IV Diagnostic Radiology - Uroradiology
Uroradiology
 Formation of kidneys
o Renal parenchyma results from fusion of several segments in utero
o Each segment is functionally independent
o Abnormal fusion  lobulation or junctional segment (residual segment)
o  Pseudomasses (fusion may deviate from normal)
 Visualisation of cortex and medulla requires CT contrast enhanced scan at different

vascular phases
o i. Cortical phase and arterial phase
o ii. Parenchymal phase (in cortex)
 Different sequences in MRI

*Contrast always given in Tw
o T1w (contrast)
o T2w (no contrast)
o T1w fat saturation
o Gd-enhanced, T1w
Choices of investigation
 1. Plain radiograph (KUB)
 2. Intravenous urogram (IVU)
 3. Ultrasound
 4. Computed tomography
 5. MRI
 6. Angiography
 (Fluoroscopy): no longer frequently used
1. Plain radiograph (KUB – kidney, ureter, bladder)

 Kidneys
o 1. Calcification
o 2. Size (should be 2.5 vertebrae in height)
o 3. Outline
o 4. Position (slants outward, with upper pole more medial)
 Ureter (NOT seen on plain radiograph)
o Should trace the course by landmarks
 Tips trans processes
 Along sacro-iliac joint
o  Presence of stone: along course of ureter
 Bladder
o Calcification
o Outline (distention)
2. Intravenous urogram (=intravenous pyelogram) (rarely used, replaced by CT KUB/CT urogram)

 IV administration of iodinated contrast media
 Excreted by kidneys via glomerular filtration
 Images taken at different phases (opacifies system at various phases)  allowing the
assessment of different aspects of the urinary tract
 Opacifies:
o 1. Pelvicalyceal systems
o 2. Ureters
o 3. Urinary bladder
 A series of radiographs
o Preliminary KUB: stone
 Before injection of contrast
o 0-1 minute film: nephorgram (kidney)
 Immediately after injecting contrast
 Visualise renal cortex (where contrast goes first)
o 5 minute film: excretion, bladder
o 10-12 minute film: calyces
 With abdominal compression  distend calyces (temp. obstruction)
allowing more contrast to collect
o Release film (supine + prone): drainage
 Release compression (if no obstruction  flows into ureter, bladder)
o Post-micturition KUB – hold up
 Look for abnormal collection of contrast
3. Ultrasound
 Assesses:
o 1. Renal size and morphology
o 2. Renal parenchyma
o 3. Masses: cyst vs. solid masses (unlike in X-ray/IVU unable to differentiate)
o 4. Obstruction: hydronephrosis
o 5. Renal vessels (Doppler imaging): transplanted kidneys, renal a. stenosis
 Veins are easier to visualize (larger), arteries are harder (smaller)
4. Computed tomography
 Involves radiation creating multiple images  usually transverse sections
 Indications
o 1. Further characterization of abnormalities seen on IVU, KUB, US
o 2. Renal colic (non-contrast CT – 1st line for renal colic)
o 3. Cancer staging: stage dependent on involvement of renal vein and IVC
o 4. Renal trauma
o 5. CT angiogram for renal artery stenosis
Examples of using CT (and CT urogram)

5. MRI
 Allows for sagittal plane (unlike CT, which only offers transverse/axial plane)
 Indications
o 1. Further characterization of abnormalities on CT urogram
o 2. Cancer staging:
 Kidney: stage dependent on involvement of renal vein and IVC
 Bladder cancer: accuracy only 40-60%
 Non-muscle invasive: T2a
 Muscule invasive: T2b
 Tumour extension: T3 characterisation
o +/- MR arteriogram (arteriogram without invasive procedure)
6. Arteriography (uses contrast)

 Imaging of arteries involving an invasive procedure (femoral a.  renal a.)
 Indications
o 1. Diagnosis and treatment of renal artery stenosis
 Can be a cause of high blood pressure (which is difficult to control)
o 2. Embolizaiton of bleeding tumours or points
 Blocking off artery that causes bleeding due to trauma, renal biopsy
o 3. Diagnosis and treatment of arterio-venous malformation/angiolipoma
7. Fluoroscopy (less common nowadays)

 Fluorscopy unlike X-ray visualizes movement
 Different types:
o 1. Anteograde pyelogram (contrast in same direction as micturition)
 Indications
 Drainage procedure is required (nephrostomy)
 Show level of obstruction
 Procedure
 Kidney is percutaneously punctured
 Contrast injected into pelvicalyceal system
o 2. Retrograde pyelogram (contrast opposite direction, goes up ureter)
 Procedure
 Cystoscope inserted
 Ureteric catheter inserted via cystoscope into ureter
 Patient transferred to radiology
 Contrast injected via ureteric catheter
 Balloon is present to prevent contrast from flowing out
o 3. Urethrogram (image of urethra)
o 4. Micturating cystourethrogram (during micturition)
Common pathologies
1. Renal/urinary stones
 Epidemiology
o Lifetime: 12% men, 5% women
o Recurrence: 50% in 5-10 years, 75% in 20 years
 Clinical features
o Flank pain (classically loin to groin) – extremely severe
o Haematuria: irregular + spiky stone traumatizes mucosa  bleeding
 Complications
o 1. Obstruction
o 2. Calyceal rupture (rare)
o 3. Infection (due to obstruction  stagnant  predisposition)
o 4. Chronic renal impairment
 Investigations
o Non-contrast CT KUB
 Sensitivity: 97%
 Specificity: 95%
 Treatment based on size and location
o i. Renal calculi
 <1cm
 Extracorpeal shockwave lithotripsy (shock to shatter)
 Ureterorenoscopy (endoscope up ureter)
 1-2 cm
 Percutaneous nephrolithotomy (requires GA, more traumatic)
 >2cm
 Rarely: laparoscopic/open surgery
o ii. Ureteral calculi
 <5mm
 Spontaneous passage
 5-10mm
 Larger and proximal ureter stones (easier to access)
2. Randall’s plaque
 Pathology
o Small area of kidney tissue becomes injured  calcification
o Acts as a seed  lead to later development of kidney stone
 Location
o Junction between medulla and collecting system
 Ddx
o Stones
o Calcification in vessels
3. Acute pyelonephritis (parenchyma of kidney)

 Mild forms: limited use of imaging  antibiotic treatment
 Indications for diagnostic imaging  characterize cause, severity and complications
o 1. Patients at risk: diabetic, elderly, immunocompromised
o 2. Assist diagnosis when patient fail to respond to appropriate therapy after 72h
(e.g. antibiotics)
 Ultrasound
o Non-specific findings:
 Hyperechoic/hypoechoic/both: heterogeneous due to inflammation
 Focal or global renal enlargement: swelling due to infection
 Vascular defect: swelling results in increased pressure, limits blood flow
 CT
o Striated nephrogram
 Due to increased pressure and swelling in the area
 Blood supply carrying contrast give striated film
4. Emphysematous pyelonephritis (uncommon)

 Severe pyelonephritis  gas collection
 CT features
o “Bubbly” or “loculated” gas or gas within cavities (in kidney)
o Destruction of renal parenchyma
o Intra or peri-renal collection
5. Renal tumours
 Commonest: RCC (though benign more common than malignant)
 Differentiating renal lesions:
o 1. Cyst?  benign (via Bosniak classification)
o 2. Macroscopic fat?  benign angiomyolipoma (fat + muscle component)
o 3. Infection and infarction? (different clinical settings)
o 4. Exclude metastatic disease (rare to kidney) and lymphoma (widespread)
 Classification of cystic renal mass by Bosniak Classification

  Likelihood of cyst associated with neoplasm
  Non-surgical (benign in category 1 and 2) vs Surgical (category 3 and 4)
Case 1
Case 2
Case 3
Case 4
Case 5
Diagnosis: renal cell cancer

Case 6
CT: contrast vs non-contrast

 Non-contrast for stones (if give contrast, will need non-contrast first to compare
anyways), since shows up most of the time, non-contrast is sufficient
 If suspect tumour  use contrast
o Invasion
o Enhancement pattern of tumour: different from normal excretion
o Distinguish between tumour and adjacent parenchyma
 If suspect trauma  use contrast
o Grading of renal trauma by assess renal pedicles (contain artery, vein, ureter)
 severity of damage determine prognosis, management and recovery

Diagnostic Radiology - Uroradiology

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MBBS IV Diagnostic Radiology - Uroradiology

 Visualisation of cortex and medulla requires CT contrast enhanced scan at different

 Different sequences in MRI

1. Plain radiograph (KUB – kidney, ureter, bladder)

2. Intravenous urogram (=intravenous pyelogram) (rarely used, replaced by CT KUB/CT urogram)

Examples of using CT (and CT urogram)

6. Arteriography (uses contrast)

7. Fluoroscopy (less common nowadays)

3. Acute pyelonephritis (parenchyma of kidney)

4. Emphysematous pyelonephritis (uncommon)

 Classification of cystic renal mass by Bosniak Classification

Diagnosis: renal cell cancer

CT: contrast vs non-contrast

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