Imaging of The Urinary System

FK UNPAR
Anatomy and Physiology of Urinary System
 KIDNEY
• Retroperitoneal Organ (Right
and Left)
• Location : between vertebral
body of Th.12 through L3
• Shape : red bean or coffe bean
• Size : 10 x 5,5 x 3 cm
• Weight : 150 gram
• Left kidney have higher
position than right kidney.
 Kidney

• Hila  artery/vein/nerve,
ureter
• 2 layers: cortex & medulla
• Cortex : nephrons
• Medulla : 6 – 18 pyramids
• Medulla: Minor calices (4-
5)  Major calices (2-3) 
pelvic kidney  ureter.
 Radiology Imaging tests :

1. Abdominal X-Ray (Abdominal plain radiograph)

2. IVP
3. USG
4. CT scan
5. MRI
6. APG / RPG
7. Cystography / Urethrocystography
8. Nuclear Medicine
9. Interventional Radiology
1. Abdominal X-Ray (Abdominal plain radiograph) :

– Aim :
• detection of opaque urinary calculi
• suspicion of tumor or cyst

– Bowel Preparation is required, such as:

• light meals
• intestinal catharsis
• fasting, 6 hours before the examination.
Plain abdominal X-ray
Radiology anatomy (PAF)
Evaluation of plain abdominal radiograph:
• The radiograph include upper pole of both
kidney through inferior margin of pubic bone.
• Should not seen prominent air and fecal
material inside bowel’s lumen.
• Preperitoneal fat line, psoas line & kidney
contour shoud seen clearly in normal subject.
• Describe if there is any opacity shadow (stone
/ calcification / foreign body) at the urinary
tract projection
• Describe if there is abdominal soft tissue
mass (tumor)
• Evaluate LS spine and pelvic
Plain abdominal x-ray
plain abdominal x-ray

radio opaque stone soft tissue mass

2. Intravenous Pyelography (IVP) :

– Aim :
• detection of anatomy and renal function
• assess pelviocalyceal systems, ureters and bladder
• detection of nonopaque stone
• detection of renal tumor

– Bowel Preparation is needed : light meals, intestinal

catharsis and a clear liquid diet
– Mild dehydration
– Iodine contrast media (water soluble)  intravenous
injection
Radiology Anatomy
Indication :
• Suspicious of urinary tract malignancy, e.g.: gross hematuria
• Abdominal mass, possibility from the kidney or there is
infiltration to urinary tract structure.
• Recurrence of urinary tract infection
• Suspicious of urinary tract obstruction, e.g. : HP
• Suspicious if there is urinary trauma
• Unknown cause of abdominal colic

Contraindication :
• Contrast allergy
• Renal failure
• Severe dehydration
Serial photo :

2.a. 5’ & 10 ‘:
• To see contour and function of kidney, pelviocalyceal,
and proximal ureter
• Compress the patient on the pubic symphisis to hold the
ureter. Then the anatomical structure of pelviocalyceal
and ureter can visualize clearly.
• Tomography perform in 10’ after contrast administration
if the kidney contour and pelviocalyceal system can not
clearly visualized because of prominent air, fecal
material or other caused.
• AP supine position.
• Film : 24 x 30 cm
2.b. 20’ :

• To see contour and function of kidney, pelviocalyceal,

ureter, and filling of urinary bladder
• If one of both pelviocalyceal system and ureter are not
seen until 1 hour or 2 hours. In some circumstances, it
should wait until 24 hours.
• AP supine
• Film : 30 x 40 cm
2.c. 30’ :
• To visualize whole ureter and anterior wall of urinary
bladder.
• To ealuate pelviocalyceal and ureter drainage.
• Prone position
• Lateral position if needed
• Film : 30 x 40 cm

2.d. full blass :

• To evaluate distal ureter and urinary bladder.
• Film : 18 x 24
• If the result satisfied, the ask the patient for
mucturation.
2.e. Post voiding:
• To know, is there any obstruction of ureter,
marked by contrast retain and to know of urinary
excretion from bladder to urethra (stasis).
• Film : 18 x 24 cm.
Serial photo BNO-IVP
Serial photo BNO-IVP
Serial photo BNO-IVP
Serial photo BNO-IVP
Ultrasonography
3. USG (Ultrasonography) :

– a noninvasive procedure, completely safe

examination method, little stress to the patient
– Aim :
• assess renal size for evidence of chronic
parenchymal disease
• obstruction (hydronephrosis, hydroureter)
• screening test for renal mass lesions (clearly
differentiates cysts from solid masses)
• detect polypoid bladder tumours (not sensitive
for "flat" or very small tumours)
– No preparation is required.
 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 collection-
tunica, 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
Renal US
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4. CT (computed tomography) :

– Aim :
• without contrast : accurate in showing urinary tract
calculi (including those not opaque on plain AXR)
• contrast media : renal function, obstruction
(hydronefrosis, hydroureter)
• best test for renal tumours  performed before and
with IV contrast
• shows adjacent retroperitoneal structures (eg lymph
nodes)
• excellent for renal trauma

– CT urography
CT Scanner
CTU : CT urography
5. MRI
• Using a strong external magnetic field
• Superior to evaluate soft tissue organ
6. Intervention angiography :

diagnostic and treatment

Renal angiography
 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 urethra-
strictures, 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-perc neph to evaluate
residual stones, evaluate site of ureter
obstruction, dx ureteral fistulas
( Some Cases )
Plain Abdominal Photo
Plain Abdominal Photo
Plain Abdominal Photo
Plain Abdominal Photo
PAF IVP
USG
USG
USG
USG
urethrocystography
PAF
Plain photo
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B
C
CT Angiography
Wilhelm Conrad Roentgen (1845-1923)