Urinary Tract Imaging- Basic

Principles
Campbells Chapter 4
Christi Hughart, D.O.

Plain Films
Scout film, primary survey, to follow known
stones, check placement of
catheters/stents/drains/foreign bodies
False +: vascular calcifications, bowel opacities,
phleboliths, appendicoliths, GS
False -: stone over sacrum/ilium, radiolucent (uric
acid)
If scout before ESWL shows no stone, may need
to reassess

Plain FilmLeft Distal Ureteral Calculus

Contrast Films
Rapidly concentrated by kidneys and opacifies urinary
tract
Low osmolar nonionic contrast material (LOCM)- 50%
less osmolar load- fewer complications than high osmolar
Reactions: dose related or idiosyncratic
Allergic, CV changes, renal toxicity, shock
Tx- antihistamines, beta agonist, epinephrine
Renal toxicity risk (average patient)- 1%
Direct toxicity to renal tubules, ischemia, altered circulation,
precipitation of uric acid
Prevention- well hydrated, LOCM, small load

IV Urography

Renal parenchyma, collecting system, ureter

Evaluates- urothelial abnormality, hematuria, urolithiasis
+/- bowel prep/npo
Scout, +/- obliques
Contrast- bolus or drip
Nephrographic phase- immediate to first minutes- parenchyma
Pyelographic phase- 5 minutes- collecting system
+/- compression, oblique- calyces, prone to distend ureter, uprightrenal ptosis/layering in severe hydro, post-void- evaluate
BOO/diverticulae/filling defect

Normal Urogram

Urogram with Prone Filmbetter visualization of ureters

Loopography
Imaging of urinary conduit or diversion (always order with indication
clearly explained)
Reflux required to see ureters if no IV contrast used (constrast
sensitivity not contraindication)
If non-refluxing anastamosis- need IVU, antegrade nephrostomy, CT,
MRI
Indications- hematuria, stones, stoma stenosis, loop ischemia, urinary
fistulae, urine leak, stricture at anastamosis, hydro, tansitional cell
cancer surveillance
Prep- bowel prep if previous contrast, antibiotics, GU irrigant
Contrast goes in thru catheter
Scout, supine, conduit distension, drainage film

Static Cystourethrography
Evaluate bladder lesion, rupture, leak, s/p
trauma/sx- bladder integrity/anast/fistulas
Scout, fill bladder with 200-400 mL
contrast via catheter, A/P and obliques
(shows extravasation posterior to bladder),
post-drainage film

Voiding Cystourethrogram
(VCUG)
Functional and anatomic evaluation of bladder
Typically for children with recurrent UTIs
Dx- reflux, urethral valves, ureterocele, dysfunctional voiding, urethral
strictures, bladder/urethral diverticula
Scout
Pediatric: 5 or 8 F feeding tube, fill bladder with contrast (age +2 x
30)
Adult: standard catheter
Film during filling- bladder pathology, early reflux
Films during void- reflux, urethral abnormality
Oblique- evaluate grade 1 reflux, males
Post-void film

Normal Male Cystogram

VCUG

Retrograde Urethrogram (RUG)

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

Normal RUG

Retrograde Pyelography
Evaluate renal collecting system and ureters
Indications- hematuria, contrast sensitivity, suboptimal
IVU, needs cysto
Pre-op- get sterile urine culture
IV sedation
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

Normal RP

Nephrostogram
Antegrade urogram- inject contrast into
nephrostomy tube
Indications- post-sx to evaluate for urine
leak, post-perc neph to evaluate residual
stones, evaluate site of ureter obstruction,
dx ureteral fistulas
Prep- sterile urine sample, +/- antibiotics

Ultrasound

Grayscale and doppler

High frequency- high resolution but low penetration depth
Renal- parenchyma, solid vs cystic, hydro
Use with IVP to evaluate hematuria
Assess allografts, congenital abnormalities, stones
Cortex vs medulla- pyramids (medulla) less echogenic than cortex

Adrenal- CT/MRI better except in peds (no RP fat)

Nodules, cysts, hemorrhage, location, tumors
Cortex hypoechoic, medulla echogenic

Bladder- examine wall, lesions

Transvaginal, transabdominal, transrectal

Normal wall >= 6 mm
Echogenicity in bladder fluid- debri, FB, infection
PVR, bladder volume
Ureteral jets- should appear in 15 minutes unless obstruction exists

Prostate- transrectal, access for biopsy

Ultrasound (cont.)
Scrotal Use high frequency probe (up to 10 MHz)
Evaluate- mass, pain, torsion, orchitis, epididymitis, hydrocele,
hernia, varicoceles
Testicle- granular, 4 x 3 cm, small anterior fluid collectiontunica, epididymis- hyperechoic
Veins- >2mm= varicocele- evaluate in erect position with valsalva
Urethral Male- evaluate stricture- scar length and depth, longitudinal along
phallus or intraluminal
Female- diverticulum

CT

Contrast- parenchyma, adrenals

3-D or CTA- evaluate vascular abnormality
100-150 mL IV bolus injection
Renal Precontrast- stones, parenchyma, vascular
calcifications, renal contour
Corticomedullary- 30 sec- cortex vs medulla
Nephrographic- 100 sec- uniform enhancement of
parencyma (masses)
Pyelographic- excretory- collecting system
Left renal vein- anterior to aorta, inf/post to SMA
Right renal vein- extends posterolateral from IVC

CT (cont.)

Adrenal Malignancy, mets, functional adenoma

Adenoma- HU <0
HU >20- ? Mets- do perc bx
MRI if suspect pheo
Bladder Depends on amount of distension

Prostate/seminal vesicle To detect abscess or cyst

If prominent median lobe- appears to extend into bladder

CT urography Enhanced CT of ureters

CTA
Rapid contrast injection with helical CT
during arterial phase
Soft tissue and bone reduced
3D reconstruction
Indications- prep for donor nephrectomy,
eval extra vessels to eval UPJ obstruction,
renal artery stenosis

MRI
No iodinated contrast
Soft tissue resolution better than CT
Contraindications- pacer, aneurysm clips, FB,
prosthesis
Allignment of protons in response to external
magnet- radiofrequency applied causes difference
in their energy
T1- fluid dark, fat bright
T2- fluid bright, fat dark

MRI (cont.)
Renal- do if need cross-sectional images but contrast contraindicated, will
not evaluate stones, determine tumor thrombus in IVC, cortex bright on
T1
Adrenal- adenomas contain more fat than cancers/pheos, pheo bright on
T2, gland seen easily on T1, T2- adrenals isodense with liver
Bladder- to id invasion of wall by transitional cell cancer or other pelvic
neoplasms (on T2)
Prostate- evaluate prostate cancer for capsular invasion. T1-distinct from
surrounding fat/seminal vesicles (intermediate intensity), T2- peripheral
zone (high intensity), central (intermediate), neurovascular bundles bright,
seminal vesicles (high)
Urethral- intraluminal coil to evaluate stricture/diverticulum
MRU- to id obstruction- ureters/collecting system- T2- fluid bright,
tissue dark (cant distinguish stone from clot/tumor)

MRA
Gadolinium
Indications- abdominal aorta, ranal artery
stenosis, pre-donor nephrectomy

Nuclear Scintigraphy
Physiologic and anatomic info
TC-99 m (t = 6 hrs)
MAG3- cleared by tubular secretion, no
glomerular infiltration- evaluate renal function and
renal plasma flow
DTPA- glomerular filtration- evaluate obstruction
and renal function
DMSA- cleared by filtration and secretion- renal
cortical image

Diuretic Scintigraphy
For hydro not necessarily caused by
obstruction
Done with DTPA or MAG3 (better for renal
insufficiency)
When tracer reaches collecting system,
diuretic given and t calculated based on
slope of curve given in response to diuretic

Renal Cortical Scintigraphy

DMSA to evaluate for cortical scars or
pyelo
Do 3 months after infection